Over the last two decades, the value of examining the fetal heart has moved from an
experimental procedure of diagnostic curiosity to a front-line form of evaluating fetal
cardiac health and disease. There have been numerous advances in the associated technology, including high-resolution imaging, the introduction of reliable color flow and
pulse Doppler, and M-Mode and continuous-wave Doppler recordings in some instruments. Such advances continue, with the potential for 3D imaging using spatiotemporal image correlation (STIC) and full-volume fetal technology.
The techniques used by obstetric sonographers in all fields, including physicians
from the fields of radiology, obstetrics, and pediatric cardiology, together with technologists who support and do most of the scanning, require a fundamental understanding
of ultrasound as well as anatomy, physiology, and the various cardiac pathologies that
occur in the fetus. This book addresses these fundamentals, providing correlations by
means of diagrams and images of fetal cardiac morphology and pathology. The scans
are quite unique, having been collected over several years by the principal author,
Dr. Enrico M. Chiappa, from his laboratories in Italy, and provide exquisite echocardiography of normal and congenitally malformed hearts. These are complemented by
the excellent pathological images of Dr. Andrew C. Cook and Dr. Gianni Botta, who
provided high-quality images of normal and pathological fetal heart conditions, which
are displayed as support for the echocardiographic images.
The organization of this book is oriented toward practitioners. The first section provides general guidelines for imaging the fetal body and heart, for segmental analysis, and
for diagnosis. The second section takes a view-oriented approach, describing first the
transverse views and then the longitudinal views of the fetal body and how each echocardiographic projection best displays a particular pathological entity. The third section contains essential information pertaining to the new technique of 3D/4D echocardiography
and the role of the pathologist in heart disease, which expands further the value of this
text for providing references and comparisons with standard imaging techniques.
The authors obviously gave a great deal of thought to this project â&#x20AC;&#x201C; from the choice
of images in the text, which include the clearest descriptions and labels, to the accompanying DVD, which contains complex moving echocardiographic images. The
objective is to provide the reader with something greater than a static representation
of the fetal cardiac morphology while retaining the ability to refer directly to morphological comparisons and consult with the text for greater detail. This work will have
great appeal to physicians and technologists involved in obtaining and interpreting such
images and will provide the obstetric, cardiological, and radiological communities with
an excellent reference for comparing cases seen in their daily practice.

CHAPTER 2 • The Four-Chamber Indice
View

IX
IX

Preface
by Enrico M. Chiappa

The numberr off congenital heartt diseases detected in utero is still low, even in countries
with well-advanced screening programs. Only 20% off new cases off congenital heart
disease come from
m traditional high-risk
k pregnancies. Ultrasound screening off all pregnancies is therefore necessary to improve the detection rate off congenital heartt diseases
and to manage them
m mostt effectively. However, prenatal screening studies have shown
widely divergentt results, with low detection rates in mostt cases. Several reasons have
been advocated to explain why these programs seem
m to fail, and differentt solutions have
been proposed to improve the success rate. There is a broad consensus thatt examiner
skill plays a crucial role in this setting and thatt appropriate training is mandatory.
Itt is ourr belieff thatt people responsible forr fetal cardiology units in centers off excellence should investt resources to fully educate the personnel involved in prenatal ultrasound screening. To do this, a fundamental step is to improve, simply and comprehensibly,, theirr knowledge aboutt the anatomy off the fetal cardiovascularr system. As Prof.
Robertt Anderson beautifully stated in a recentt review [Anderson RH, Razavi R, Taylorr AM (2004) Cardiac anatomy revisited. J Anatt 205:159-177], one convention off the
human anatomy is thatt all structures should be described in the setting off theirr anatomical position within the body and off the relationship off organs to each other. This convention has nott always been strictly applied when describing the heart. In the past, the
so-called Valentine approach has prevailed, thatt is, the convention off representing the
heartt isolated from
m the surrounding structures and balanced on its apex, with the atria
above the ventricles. This approach generated confusion,, particularly in the field off congenital heartt disease,, where the position off the heartt and the location off the cardiac segments is variable. Therefore, as Prof. Anderson wrote: “students should be introduced
to the anatomy off the heartt as itt lies within the body, as revealed with clinical tomographic images”. To this purpose, the use off tomographic sections off isolated hearts,
frequently used in textbooks off echocardiography, is only partially effective in prenatal ultrasoundd examination,, where the views off the surrounding structures are much wider
and the approaches to the fetal thorax more variable than in the postnatal setting.
Wee decided,, therefore,, to perform
m imagee sections off thee wholee fetall body to obtain
n tomographic views off the heart,, thus showing the relationship betweenn cardiac andd extracardiac
structures. As indicated
d in
n Chapterr 21,, tomographic sections off the fetal body were obtainn
ed
d in
n a limited
d numberr off fetuses underr the gestational age off 20 weeks following informed
consentt off parents andd in
n strictt adherence withh the Italian
n legislationn onn this subject. The
ideaa to obtainn these types off sections stemmedd from
m almostt 20 years off fundamental work
by Alff Staudach
h [Staudach
h A (1989) Sectional fetal anatomy in
n ultrasound. Springer],, with
the advantages off computerr technology in
n photographic andd ultrasoundd images.
Ratherr than systematically describing congenital heartt diseases in the fetus, the goal
off this work is to provide a basic tool forr understanding the normal and abnormal
echocardiographic anatomy off the fetal heart. In this way,, this textbookk is complementary
and not alternative to the more extensive publications on this subject.
The firstt section
n off this bookk describes the basic principles off diagnosis,, illustrating
assessmentt off the laterality off the fetal body,, the visceroatrial arrangement,, andd the cardiac position. This orderr reproduces the logical sequence the examinerr shouldd follow when
studying the fetal heart. Inn the second
d section,, all echocardiographic projections in
n the fe-

X

Preface

tus are described, from those most familiar to obstetric sonographers, to those usually obtained only by pediatric cardiologists. Particular emphasis is given to imaging the shortaxis sections of the fetal body, which has recently proven to be a powerful method for
complete examination of the fetal heart. The chapters pertaining to echocardiographic projection are in logical sequence in two series: the transverse views of the fetal thorax, presented from the bottom to the top, and the sagittal and parasagittal views, presented from
the right side to the left side. The sequence of these planes in some ways imitates the
changes of the scanning plane that can be obtained by the examiner tilting or translating
the probe manually with traditional probes or electronically with modern 3D ultrasound.
The third section consists of two chapters. The first describes the essential use of modern 3D/4D ultrasound techniques to image the fetal heart, including new volume manipulation, such as spatial and temporal image correlation (STIC), and rendering, such as glassbody, minimum-transparent, and inversion modes. The second chapter emphasizes the importance of autopsy in providing information regarding anomalies of the fetal heart and
describes optimal techniques for dissection and photography of the autopsic specimens.
This section emphasizes the crucial role of the echocardiographic projections described
elsewhere in this book, which maintain their fundamental role in the comprehension of
new advances in ultrasound and the future application of MRI/CT in postmortem studies
of the fetal heart. These two different chapters are incorporated in this section because the
approach to volume data sets of 3D/4D sonography and to blocks of pathological specimens shows many similarities. The information displayed by either technique depends on
the level at which the examiner cuts the cardiac volume, no matter if a digital tool or a
pathologist’s blade is used. Moreover, some image-rendering techniques are comparable
with the fine-art photographic technique available to the pathologist to display with outstanding clarity the subtle details of congenital heart disease in fetal heart specimens.
The problem of image orientation was thoroughly discussed with cardiac morphologists Andrew C. Cook, Gianni Botta, and Robert H. Anderson from the very beginning of the editorial phase of this book. The reader will notice that some anatomical images of the transverse sections of the thorax do not “at first sight” match the
echocardiographic images. We decided to maintain the echocardiographic images in
their original caudocranial orientation, a standard that is accepted in MR and CT imaging, rather than flip them horizontally, which would reduce the resolution of the digital clips on the accompanying DVD. We decided, instead, to display a compass with
every image, thus illustrating its orientation.
As to the abnormal heart, rather than fully describe a single congenital heart disease in different projections, the book and DVD describe how a specific projection appears in the normal heart and in some abnormal conditions. Although we understand
that this is not sufficient for a comprehensive assessment of a specific disease, we believe this type of presentation reproduces the usual approach of the examiner, who is
initially unaware whether the case being examining is normal or abnormal. The more
the examiner understands the normal anatomy, the easier it is to recognize what is wrong.
Ultrasound assessment of the heart, whether in fetal life or postnatally, is based on
moving images, and books therefore have limited value in teaching echocardiography.
With recent advances in ultrasound systems, storing multiple digital frames and clips
with superb image quality has become a reality. These advances have brought innovative applications to the clinical field and can be utilized as powerful multimedia presentations for teaching purposes. The accompanying DVD is such a tool. This is a complex DVD that includes more than 300 clips of normal and abnormal views of the fetal heart frames of each topic, with 11–13, representing a single cardiac cycle, each of
which is displayed in a loop. The DVD in many respects is not simply a copy of the
book. The text window contains essential information of the case being presented, and
– in the four-chamber section in particular – a short unit describes the essential features
of each specific congenital heart disease. We believe this presentation will be a highly
useful tool for all those interested in the echocardiographic study of the fetal heart.

Introduction
Congenital heart diseases are the most common congenital malformations, affecting six to eight per
1,000 live births [1-3], and their prevalence in abortuses has been shown to be even higher [4, 5]. Moreover, heart diseases are the leading cause of death
among infants with congenital anomalies, causing
nearly 20% of neonatal deaths and up to 50% of infant deaths due to congenital anomalies. Recent studies have demonstrated a positive impact of prenatal
diagnosis in morbility and mortality rates in specific groups of congenital heart disease [6-8]. Only 20%
of congenital heart disease in the fetus occurs in
high-risk pregnancies; therefore, routine screening
of all pregnancies is necessary. Prenatal screening
cannot be conferred solely to pediatric cardiologists
because of the limited number of these specialists.
The alternative, chosen in many developed countries,
is to assess the heart in a simplified form – the fourchamber view – during routine “anomaly scan” at
18-20 weeks’ gestation and to provide extra training for all obstetric sonographers. The anticipated potential of the four-chamber view to detect most of
the severe cardiac anomalies has been disproved by
discouraging false-negative rates of congenital heart
disease in many screening programs utilizing this
projection only [9-11]. Most forms of conotruncal
anomalies, such as transposition of the great arteries, tetralogy of Fallot, truncus arteriosus, and double-outlet right ventricle, may appear completely normal in the four-chamber view. Some screening programs have demonstrated that the detection rate for
congenital heart disease is significantly improved by
an extended cardiac examination [12-16]. Therefore,
there is a growing consensus that assessment of the
ventriculoarterial connection should be included in
the routine fetal anomaly scan [17, 18]. Detailed
fetal echocardiography may identify most significant congenital heart diseases, but it is time consuming and requires special knowledge of the normal and abnormal cardiovascular system, which is

not a requirement for every examiner. Most authors
agree that to improve results in fetal echocardiography, efforts are needed to expand the skills of the
operator involved with a clear and effective educational method. Positive results of training sonographers to recognize cardiac abnormality in the fetus have been proven [19, 20]. We believe the information provided in this work will be most useful
to that end.
The background of this project comes from two
main considerations. First, whether in fetal life or
postnatally, echocardiographic diagnosis is based on
moving images. Consequently, books have limited
value in teaching echocardiography, and the use of
videotapes is time consuming and relies on inconsistent image quality. With recent advances in ultrasound systems, storing multiple digital frames and
clips with superb image quality has become a reality. These advances have brought innovative applications into the clinical field and can be utilized in
powerful multimedia presentations for teaching purposes. Second, imaged sections of cardiac specimens
are usually compared with their corresponding
echocardiographic views in textbooks of echocardiography. These sections are mainly obtained from
isolated hearts because they are technically easier and
less time consuming to obtain. Nevertheless, imaged
sections of the whole body are better tools by which
to understand the relationship between cardiac and
extracardiac structures. This understanding is particularly necessary in fetal echocardiography, where
the number of visible structures around the heart is
much greater and the approaches to the fetal thorax
are more variable.
For this project, we created a digital presentation,
included in the DVD, in which images from tomographic sections of the whole fetal body are combined with dynamic echocardiographic images of
normal fetuses and of some of the most common congenital heart defects. All projections are accompanied by schemes and full text for better understanding. We believe this collection will be a major tool
for all those interested in studying the fetal heart.

4

Echocardiographic Anatomy in the Fetus

Equipment
A thorough discussion of the principles of ultrasound
in prenatal diagnosis is beyond the scope of this project, and the reader must refer to papers and books
that extensively cover this subject [21-24].
General guidelines for instrumentation in fetal
echocardiography recommend high-resolution ultrasound machines. Impressive progress has been made
in ultrasound probe resolution over the past decade,
thanks also to the very fast frame rate achieved by
parallel processing in which the transducer transmits
one line and receives two, resulting in a doubling of
the previous rate (Fig. 1.1). Using modern probes,
fetal echocardiography can now be performed transvaginally at 11-14 weeks gestational age and transabdominally at 12-15 weeks gestational age [25, 26].
Because of its effectiveness in identifying fetuses at
risk for chromosomal and cardiac anomalies, nuchal
translucency screening is creating an increasing population of fetuses in need of complete echocardiography [27-29]. Although diagnostic examination can
be obtained at an early gestational age in selected cases, further scan between 18-22 weeks gestational age
is recommended [30-32].
Transducer frequency should be as high as possible to obtain the best resolution. In the second
trimester, a 5-8 MHz transducer is suitable in most
cases. Nevertheless, a 3 MHz transducer may be required when deep penetration is necessary due to maternal overweight, an anterior placenta, polyhydram-

a

nios, or an unfavorable fetal position. Either sector
or convex probes may be used, with advantages and
disadvantages for each. Sector probes are the ones
most preferred by cardiologists because they are designed to give the best performance in cardiac applications. Moreover, because of their diverging beam,
sector probes are most useful when the acoustic window is limited. In the presence of polyhydramnios or
increased thickness of the maternal wall, a sector
transducer, thanks to its small footprint, can be placed
into the umbilical cavity to get closer to the fetus and
thus improve image quality. On the other hand, because of the divergent direction of the ultrasound
beam from the probe surface, line density (and lateral resolution) decreases as depth increases.
Conversely, convex probes allow for a more ample angle of visualization, making orientation on the
fetal body easier and guaranteeing a more homogeneous resolution over the whole area of investigation.
Because of the moving structures of the heart and
the high heart rate in the fetus, the primary goal in
ultrasound setting is to obtain a frame rate as high
as possible. Cross-sectional imaging (Fig. 1.2a) is still
the modality most commonly used to study the fetal heart. In this setting, a presetting with compressed
gray scale, narrow ultrasound beam, single focus, and
absent or very low persistence is recommended. For
inexperienced obstetric sonographers, it is important
to remember that such a presetting exists and must
be selected because an obstetrical presetting employs
a frame rate too low to reliably image the fetal heart.
To avoid damage to the fetus, cardiac presetting

b

Fig. 1.1 â&#x20AC;˘ Ten years separates these two (a, b) four-chamber echocardiographic sections (a 1997; b 2007). The improvement in resolution of the new generation of probes is seen in the 2007 image, where a higher degree of anatomic detail is appreciated

1 • General Guidelines

should also be used to ensure that spatial temporal
average power output for color and pulsed Doppler
is less than 100 mW/cm2.
The possibility of image magnification using the
zoom allows for better definition of the size and
structure of the fetal heart, whereas the cine loop now
makes it possible to record a long series of consecutive digital images that can be immediately reexamined as single frames. This function is particularly
useful for identifying structural or flow anomalies
that may be overlooked should the images be evaluated in real time only. With recent instrumentation,
storing digital clips on the hard disk of the built-in
computer is possible. Instruments equipped with
cine-loop and digital-clip storing capabilities provide
a user-friendly system in which moving clips and
still-frame digital images are readily accessible for
review – a powerful means for off-line analysis and
case discussion that is largely superior to professional
videotape recorders.
When investigating the fetal heart, the use of
Doppler is complementary to the morphological
study with the cross-sectional technique. To allow
an accurate flow evaluation, the insonation angle

a

d

b

5

should be as parallel as possible to the estimated
flow direction under study. The estimated error of
flow velocity is negligible for insonation angles less
than 20-30°. Routine use of color flow mapping
(CFM) (Fig. 1.2b) is helpful to assess the symmetry of ventricular filling and to detect significant regurgitation of the atrioventricular valves related to
major congenital heart defects. CFM facilitates positioning of the sample volume of pulsed Doppler
in the region of interest. On CFM evaluation, the
color box should be kept as small as possible, with
maximum scale velocity around 50-90 cm/s in arterial districts and 7-20 cm/s in venous districts. On
pulsed Doppler (Fig. 1.2c), the sample volume must
be kept small (2-4 mm), with a wall filter at 150300 Hz for arterial vessels and 50-100 Hz for venous vessel. Pulsed Doppler tracings should be obtained during periods of fetal apnea to avoid the flow
waveform modifications produced by respiratory
movement. Continuous Doppler is considered optional but may be necessary to assess precisely the
peak velocity of high-velocity jets, such as those in
tricuspid valve regurgitation in pulmonary valve
atresia with intact ventricular septum (Fig. 1.2d).

Due to the high frame rate and time resolution,
M-mode tracing (Fig. 1.2e) is the mostt accurate
method
d to provide informationn onn wall thickness,, ventricularr diameter, and shortening fraction. However,
the application off M-mode in the fetus is limited because M-mode measurements require an ultrasound
beam
m orientation thatt is difficultt and sometimes impossible to obtain. Colorr M-mode colorr (Fig. 1.2f)
combined
d withh pulsedd Dopplerr has been
n demonstrated
to be an invaluable tool in assessing fetal arrhythmias.

• The sagittall plane, also called the median plane,
runs in a true anteroposteriorr direction. When
traced through the median axis, the body is divided into rightt and leftt halves.
• The coronall plane, alsoo called
d frontall plane,, is a longaxis plane off the body perpendicularr to the sagittal
plane. When
n itt is traced
d through
h the central axis,, it
divides the body into anteriorr and
d posteriorr halves.
• The transverse plane, also called the horizontal
plane, is a short-axis plane off the body perpendicularr to the sagittal and coronal planes. Itt divides the body into superiorr and inferiorr portions.

Major Planes of the Body and Heart
The majorr planes off the body are the sagittal, coronal, and transverse planes (Fig. 1.3) as detailed in
the following:

a

c

The long axis off the heart in postnatal life lies in
a plane thatt runs from
m the leftt hypochondrium,, where
the cardiac apex is located, to the rightt shoulder. In
the adult, itt is typically inclined 45° to each major

b

Fig. 1.3 • Sagittal (a),, coronal (b),, and transverse (c) planes off the body
shown on pictures off a doll

1 • General Guidelines

body plane. However, inclination of the cardiac long
axis relative to the transverse plane may change with
the positions of the diaphragm. In the fetus, the heart
is more horizontal than in postnatal life because the
lungs are deflated and the liver is relatively large.
Therefore, the cardiac long axis sits on a plane nearly parallel to a transverse plane of the fetal body. On
the contrary, the short axis of the heart, which is perpendicular to the long axis, is almost parallel to the
sagittal plane of the fetal body (Fig. 1.4).

7

By convention, two major planes can be distinguished along the long axis of the heart: the four-chamber plane and the two-chamber plane. The first plane
is perpendicular to the inlet and trabecular ventricular septum, whereas the second plane is parallel to it
(Fig. 1.5a). The short-axis plane includes a series of
parallel planes, all perpendicular to the long axis of
the heart. Classically, the short-axis plane at the level of the mitral valve and the level of the papillary muscles of the left ventricle are considered (Fig. 1.5b).

Basic Probe Manipulations

Fig. 1.4 • Long and short axis of the fetal heart and body
are simulated on a picture of a doll

a

In general, echocardiographic study of the fetal heart
requires small probe manipulations. In fact, because
of the small size of heart and the relatively large distance from the application point of the probe, small
movements of the transducer produce great changes
in the scan plane.
In ultrasound examination, the section plane can
be modified by three fundamental manipulations of the
probe: rotation, angulation, and translation (Fig. 1.6):
• With rotation, the scan plane is changed by turning the transducer clockwise or counterclockwise while maintaining the footprint in a fixed
position.
• With angulation, the scan plane is modified by
tilting the probe in the cranial, caudal, right, or
left direction. In this case also, the application
point of the probe is maintained relatively fixed.
• In translation, the scan plane is left unchanged
while its application point is changed by sliding
the transducer on the skin.

b

Fig. 1.5 • The two planes along the long axis of the heart are shown on a heart diagram, simulating an apical approach
with the probe (a). The two basic short-axis planes of the heart are shown on a heart diagram: at the level of the mitral
valve (or the base of the heart) (1) and at the level of the papillary muscles (2) (b). (See more in the respective chapter)

Fig. 1.7 â&#x20AC;˘ Four-chamber view in the same fetus with unfavorable anterior presentation of the spine. The shadow of the
spine (a) ((yellow open arrow
w) masks the heart, which is barely visible. The heart is brought out of the shadow (b) (yellow
(
open arrow)
w by translating the probe to the left side of the spine. A four-chamber view of reasonable quality is obtained
from the posterior part of the left hemithorax

Translation of the scan plane is more difficult to
learn but is particularly useful in prenatal ultrasound
examination because it provides a similar projection
from different scanning angles. This allows, for ex-

ample, the targeted organ to be brought out of the
shadow of proximal structures (Fig. 1.7).
Translation of the scan plane may also improve the
definition of cardiac structures by allowing examination

1 â&#x20AC;˘ General Guidelines

a

9

b

Fig. 1.8 â&#x20AC;˘ Diagram simulating a transverse section of the fetal thorax at the level of the four-chamber view within the amniotic cavity (black area). The apical four-chamber view (a) can be changed to a transverse four-chamber view (b) by translating the probe (yellow
(
arrow
w) on the motherâ&#x20AC;&#x2122;s abdomen while maintaining the section plane unchanged

with axial instead of lateral resolution (Fig. 1.8). In
fetal echocardiography, similar projections of the heart
can be obtained from different positions of the transducer because the lungs do not represent an obstacle
to imaging, as they are filled with fluid and not air.
This allows projections through the rib cage, even from
the back, which are unobtainable postnatally (Fig. 1.7).
Nevertheless, projections from the back produce attenuation of the ultrasonic energy, particularly in the
third trimester when bony structures of the thoracic
cage absorb most of the ultrasound energy.
In general, the best definition of cardiac structures
is achieved through the fetal abdomen. If initially unfavorable, fetal presentation may change for the better by translating the scan plane or by turning the
mother on her side, having her empty a full bladder,
or having her take a little walk. Sometimes, the examination must be postponed for hours or a few days.

Axial and Lateral Resolution
The axial resolution is the shortest distance between
two points lying on the same insonation axis, which

the ultrasound system is able to represent as separate. The lateral resolution refers to the shortest distance between two adjacent points that an ultrasound system is able to represent as distinct. In virtually all cross-sectional ultrasound systems, the
axial resolution is better than the lateral resolution.
This implies that structures that are orthogonal to
the ultrasound beam will be better represented than
structures that are parallel. The four-chamber view
provides one of the best examples to explain this
concept. This view can be obtained in apical or
transverse orientation. Despite showing sections of
the fetal thorax across identical structures, the apical and transverse four-chamber views provide different information. In fact, in the apical approach,
the moderator band, the atrioventricular valves, and
the venoatrial connection are better represented; in
the transverse approach, ventricular-wall thickness,
ventricular transverse diameter, and foramen ovale
morphology and function are more precisely assessed. Conversely, in the apical approach, it is difficult to identify the endocardial borders of the heart
chambers and assess precisely ventricular-wall
thickness and transverse diameter of cardiac cham-

bers, whereas in the transverse approach, the moderator band and atrioventricular valves are usually
undefined (Fig. 1.9). These differences are even better appreciated on moving images than in still
frames.

Method for Comprehensive Cardiac Evaluation
As already stated, most authors agree that the routine fetal anomaly scan should include assessment
of ventriculoarterial connection, and this can be
achieved by different methods. Some authors favor
incorporating the views of the two so-called ventricular outlets [16, 17]. Others suggest using a series of short-axis sections of the fetal thorax for complete cardiac examination [33-36].
In complete assessment of the fetal heart, the experienced examiner should understand the echocardiographic anatomy so thoroughly that he or she uses the standard views not as ends in themselves but
only as reference points during a scan sequence, including a series of parallel sections from bottom to
top, from side to side, and from front to back. However, demanding such knowledge from all obstetric
sonographers for routine examination is highly unreasonable. Our teaching experience over the past 10
years has shown us that beginners or first-level sonographers can understand and more easily assess the
fetal heart using transverse or sagittal views of the
fetal body; that is, by orienting the scan plane or-

Fig. 1.10 â&#x20AC;˘ White lines on the picture of a doll simulate a consecutive series of sections with which one can investigate the
fetal body along the transverse plane, from bottom to top
(a-d),
d and along the sagittal plane, from right to left (e-h)

thogonal or parallel to the long axis of the fetal body
(Fig. 1.10). This is because the long axis of the fetal body is a reference line easier to identify than the
major axis of the fetal heart.
In particular, the transverse sections of the fetal
upper abdomen and thorax have gained a growing

1 • General Guidelines

reputation in recent years in imaging the fetal heart.
These sections resemble those obtained with magnetic resonance imaging (Fig. 1.11).
We believe that a complete assessment of the fetal heart can be obtained through a series of trans-

verse sections of the fetal body (Fig. 1.12) and can
be adopted as a standardized technique for cardiac
evaluation in screening [35].
Our goal for this project is that the reader will
gain greater knowledge of the fetal cardiac anatomy to be able to obtain a mental three-dimensional reconstruction of the fetal heart and surrounding structures. Moreover, a specific chapter describes new ultrasound technologies dedicated
to the three-dimensional study of the fetal heart.
After introduction of the spatiotemporal image correlation (STIC) technique, three-dimensional study
of the fetal heart has changed and will change
rapidly over the coming decade [37-45]. Once a
volume data set is acquired, the heart can be examined using multiple section planes, some of
which are unobtainable with cross-sectional ultrasound [44]. In addition, digitally stored volumes
can be sent to experts for analysis or second opinions. Three-dimensional echocardiography has the
potential for making the examination less operator dependent. For example, with spatial com-

A
R

L
P

Fig. 1.12 • The five fundamental transverse sections of the fetal body and their respective section planes shown on a picture of a doll: the upper abdomen (1), the four-chamber view (2), the five-chamber view (3), the arterial duct transverse
view (three-vessel view variant) (4), and the aortic arch transverse view (5)

12

a

c

Echocardiographic Anatomy in the Fetus

b

Fig. 1.13 • Four-chamber view obtained with cross-sectional technique
(a) and three-dimensional, “thick-slice” rendered image (b). Of these
two images, b more closely resembles the image of the anatomic specimen (c), in which the fetal thorax is sectioned to imitate the fourchamber view

pounding, which is still limited by a low frame rate,
the acquired volume can be sectioned automatically
in a series of parallel slices similar to those obtained by manipulating the probe with “traditional”
techniques.
Progress in echocardiography is likely to reduce
image acquisition time and provide more rapid and
simpler recognition of defects, “mirroring” the actual morphology of the heart. Indeed, the images now
produced by magnetic resonance imaging and com-

puted tomography may become so like the actual
anatomical specimens that clinicians’ and pathologists’ views may be indistinguishable (Fig. 1.13).
Continuing developments in ultrasound already
show great promise in this regard. It is also clear,
however, that for the foreseeable future, the exquisite detail of cross-sectional images, such as those contained in this work, will remain the basis of fetal cardiac imaging and the standard reference tools for examining the fetal heart.

Introduction
In
n the normal human,, the midline sagittal plane divides
the body into two sides thatt are mirrorr images off each
otherr in
n term
m off theirr skeletal andd muscularr structure.
However,, many organs withinn thee body,, evenn thosee that
are paired
d (suchh as lungs,, bronchi,, kidneys),, show a
distinctly lateralized
d arrangement. This lateralization
is mostt striking in
n unpaired
d organs. In
n the large majority off normal subjects,, the liverr is predominantly to
thee rightt off thee midline,, whereas thee stomach
h and
d spleen
aree located
d to thee left. Thee heartt sits in
n thee mediastinum,
with
h two thirds in
n the leftt side off the chestt andd its long
axis also pointing left. This pattern
n off lateralization
n is
called situs solitus,, which
h means usual arrangement.
Congenital heartt diseases occurr with increased
frequency in cases with malposition off the heartt and
otherr majorr organs. Moreover,, an abnormal heartt po-

a

sition may worsen the surgical prognosis off a particularr congenital heartt defect. Determining the precise location off the heartt is therefore an obligatory
prerequisite off the echocardiographic examination.
To precisely locate organs, preliminary assessment
off the laterality off the fetal body (thatt means understanding which is the rightt side and which the left
side off the fetus) is necessary. In fact, iff the left/right
axis is nott correctly identified,, significantt pitfalls may
resultt in establishing the visceroatrial situs, cardiac
position, and cardiac segmental analysis.
In cardiovascular medicine, there are several
examples off imaging techniques where the leftt and
rightt side off the body can be confused. The chestt Xray is one off the mostt common examples. In fact,
the film can be inspected from both sides, leaving
the examinerr uncertain as to which is the right
andd whichh is the leftt side off the body (Fig. 2.1). Needless to say, the position off the heartt orr the stomach

b

Fig. 2.1 â&#x20AC;˘ this chest X-ray,, no left/right axis marker is provided.. The film can be examined from both sides (a, b),
making impossible to establish whether the heart and stomach are in the left or right side off the body. H heart,
St stomach

16

Echocardiographic Anatomy in the Fetus

cannott be used to identify the leftt side off the body,
because location off these organs may vary. Iff a lead
markerr is placed to precisely identify one off the two
sides off the body (Fig. 2.2), the position off the organs can be established. However, mistakes are possible iff the markerr is placed on the wrong side.
Fetal echocardiography images are not immune
to such left/right axis ambiguity. In fact, transverse

sections off the fetal body can be obtained in opposite perspectives: caudocranial (the section is
viewed from the feet toward the head) and craniocaudal (the section is viewed from the head toward the feet) (Fig. 2.3). The perspective must be
the result off an imaging procedure that the operator must follow. Only when the examiner intentionally obtains one specific perspective is the
left/right axis determined by the position off the fetal spine (Figs. 2.4, 2.5). Once again, the procedure
forr determining laterality must be independent from
the position off the body organs, because organ location may vary.

Methods

Fig. 2.2 • In this chest X-ray,, a lead “R”” marker (yellow
(
w arrow
w)
has been place to indicate the right side off the patient.The
.
heart and stomach can therefore be located in the left side.
H heart, St stomach

Differentt methods off assessing laterality can be applied successfully in fetal ultrasound examination.
Since publication in the Journall off the American Society off Echocardiography in 1994, the method established by Cordes and colleagues [1] has been
adopted
d by many prenatal cardiologist. The technique
is easy to learn and quick to perform. Moreover, this
method is effective when the fetus is in transverse
position – a condition where obstetrical methods can
fail. Itt is recommended thatt the left/rightt axis be determined
d att the very beginning off the scan. When this
procedure is performed systematically and recorded
on videotape, assessing the visceroatrial situs and
heartt position is still possible, even when reviewing
the images offf line.

Fig. 2.3 • Transverse view off the fetal thorax at the four-chamber level off the heart.. The same image is displayed in the
two different perspectives:: caudocranial and craniocaudal.. However,, iff the specific perspective off each image is not known,
the left/right axis and position off the heart cannot be established

CHAPTER 2 • Determining the Laterality of the Fetal Body and Image Orientation
a

17

b

Fig. 2.4 • Simulated sagittal
echocardiographic plane
of the fetal body shown on
the picture of a doll (a).
A long-axis echocardiographic view of the fetal
body with the fetal head
displayed on the screen to
the right side of the observer (b)

Fig. 2.5 • How to obtain a
transverse view (grey area)
of the fetal body from a
sagittal view (white broken
lines) by 90° clockwise rotation of the transducer is
demonstrated on the picture of a doll (a). If the vertex of the scanning fan in
the sagittal view is placed
slightly cranial to the diaphragm, by 90° rotation of
the scan plane, a transverse
section of the four-chamber view is obtained (b).
This view is in caudocranial
orientation and the left/
right axis is inferred by the
position of the spine. Therefore, the heart is in the left
side of the chest in this case

a

Procedure
1. Obtain a sagittal view of the fetal body, whatever
its position.
2. Orient the transducer so that the fetal head is on
the right side of the observer on the video screen
(Fig. 2.4).
3. Rotate the transducer 90° clockwise to obtain a
transverse view of the fetal body (Fig. 2.5a).
4. Transverse section thus acquired will be in caudocranial perspective (Fig. 2.5b).
It is important to remember that the sequence of
these steps must not be reversed or the images electronically switched before the left/right axis assess-

b

ment is completed. Otherwise, significant errors in
interpreting the fetal anatomy may occur.
By systematically applying this method, the examiner will become familiar with the four basic presentations of the fetus (Fig. 2.6).
Once laterality of the fetal body is determined,
the examiner checks the location of the the organs
and can then assess the visceroatrial arrangement and
the position of the heart and its axis. This can be obtained through two fundamental transverse sections
of the fetal body: the upper abdomen, and the fourchamber view. Figure 2.7 simulates these two sections in the four basic presentations of the fetus in
usual visceroatrial arrangement (situs solitus) and the
heart in the left side of the chest (levocardia).

18

Echocardiographic Anatomy in the Fetus

Fig. 2.6 â&#x20AC;˘ Transverse section of the fetal trunk in caudocranial perspective illustrating the four basic presentations: face
up (1), right side up (2), face down (3), and left side up (4). Using the fetal spine as the landmark, the right and left sides
of the fetal body can be determined. For clarity, the drawings are superimposed on the picture of a doll viewed from feet
toward the head. L left, R right, S spine

Fig. 2.7 â&#x20AC;˘ Diagrams of the transverse views of the fetal body (upper abdomen and four-chamber view) in visceroatrial situs solitus and levocardia. Each pair of sections, displayed in caudocranial presentation, is shown in the four basic presentations of the fetus: face up (1), right side up (2), face down (3), and left side up (4). L left, R right

CHAPTER 2 â&#x20AC;˘ Determining the Laterality of the Fetal Body and Image Orientation

Image Orientation
In prenatal ultrasound examination, the problem of
orientation applies to each transverse view of the
fetal body. There is no international standard regarding type of orientation of these sections. Usually, obstetricians are more familiar with images displayed in craniocaudal perspective. If images with
this type of orientation are preferred, the examiner can apply Cordesâ&#x20AC;&#x2122; method following the same instructions with the exception of a counterclockwise
rather than a clockwise rotation of the transducer
in step 3.

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a

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c

Many cardiologists prefer to obtain sections in
anatomical presentation, that is, in a manner corresponding to the anatomic position of the heart within
the body (Fig. 2.8). This is obtained by switching images electronically until the desired result is obtained.
However, this process is generally very difficult for beginners and noncardiologists to obtain and understand.
Because caudocranial presentation is an international standard for orienting transverse sections in
magnetic resonance imaging and computer tomography, most echocardiographic images in this manual are displayed in caudocranial orientation. However, a compass will help the reader understanding
the type of orientation depicted in each image.

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A

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Fig. 2.8 â&#x20AC;˘ Four-chamber view a normal 25-week gestationalage fetus with usual visceroatrial arrangement and the heart
in the left side of the chest. The same view is shown in craniocaudal (a), caudocranial (b), and anatomical (c) presentation. The latter image (c) is electronically switched to display the left-sided chambers on the right side of the video
screen, as is common in pediatric echocardiography. LA left
atrium, LV left ventricle, RA right atrium, RV right ventricle,
S spine

20

Echocardiographic Anatomy in the Fetus

Whatever the preferred image orientation, it must
always be the result of an intentional choice by the
examiner, and not random, so as to always be aware
which side of the fetus is which. By following this
method, it is possible to recognize an abnormal position of cardiac and extracardiac structures, what-

ever the level of the transverse section along the caudocranial axis of the fetal body.
In our experience, maintaining the same orientation
throughout a series of transverse sections of the fetal
body more readily provides the examiner with a mental
three-dimensional reconstruction of the fetal anatomy.

CHAPTER

3

The Visceroatrial Arrangement (Situs)

Introduction
In the sequential segmental approach to diagnosing
congenital heart disease, the morphological arrangement of the atria is the starting point [1, 2]. The appendages are the most constant component of the atria.
Their shape and the morphology of their junction with
the atria always show a morphologically right or left
pattern. The morphologically left atrial appendage is
tubular and hook-shaped, with a narrow junction with
the venous portion of the atrium. The vestibular aspect of the left atrium is smooth, as the pectinate muscles are restricted to the appendage. The morphologically right atrial appendage is essentially triangular,
with a broad junction with the venous portion of the
atrium. Its internal aspect contains pectinate muscles
that extend around the atrioventricular junction and
reach the crux of the heart (Fig. 3.1) [3].

S
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Fig. 3.1 â&#x20AC;˘ In this specimen of a normal heart, viewed form
above, the upper portion of the atria is sectioned to show
the â&#x20AC;&#x153;floorâ&#x20AC;? of the atria with their appendages. The different
size of the junction of the atrial appendages (white brackes)
and different distribution of the pectinated muscles (yellow
(
dotted line) within each atrium is demonstrated. AV aortic
valve, LA left atrium, LAA left atrial appendage, PV pulmonary
valve, RA right atrium, RAA right atrial appendage

The morphology of the atrial appendages can be
identified with cross-sectional echocardiography, but
in practice, this is unreliable in fetal scanning due to
the small atrial appendages and their location outside
the standard planes [4]. Berg et al. proposed a method
of evaluating the atrial morphology in the four-chamber view that seems to differentiate between left and
right isomerism in the majority of patients [5]. The
atrial arrangement can be more easily recognized
sonographically by a transverse section of the fetal
upper abdomen. In fact, there is a close relationship
between the arrangement of the atria and the position of the descending aorta and great veins at the level of the diaphragm [6-8]. There are four possible
types of visceral and atrial arrangement: usual, mirror image, and left and right isomerism.

Usual Arrangement (Situs Solitus)
Situs solitus means the usual arrangement of the thoracic and abdominal organs found in most individuals.
There is lateralized arrangement of the organs within
the body and of the atrial appendages within the heart.
The right lung is a three-lobed structure with a short
eparterial bronchus, whereas the left lung is bilobed,
and its bronchus is long and hyparterial. The stomach,
spleen, and descending aorta are present on the left side
of the body, and the major liver lobe and inferior
vena cava are to the right of the midline (Fig. 3.2a).
The left-sided atrium is morphologically of left type,
and the right-sided atrium is morphologically of right
type (Figs. 3.2b, 3.3). In individuals with usual atrial
arrangement, a left-sided heart with apex to the left, the
incidence of congenital cardiac malformations approximates that seen in the general population.
In transverse sections of the upper abdomen, the
descending aorta sits close to the spine, slightly to
the left of the midline. The inferior vena cava is in
a more anterior position and slightly to the right of
the midline. The stomach is on the left, and the portal sinus curves smoothly to the right where the predominant liver lobe is located (Fig. 3.4).

Fig. 3.3 • The inner surface of the two atria is shown in a fetal heart with usual atrial arrangement. The vestibule of the
morphologically left atrium shows a smooth surface, whereas in the morphologically right atrium, there are extended
pectinated muscles (yellow
(
brackett) around the orifice of the
tricuspid valve reaching the crux of the heart. mLA morphologically left atrium, mRA morphologically right atrium,
MV mitral valve, TV tricuspid valve

Mirror-Image Arrangement (Situs Inversus)
The other form of lateralized body arrangement is
the situation in which the bodily organs are mirrorimaged. Although frequently termed situs inversus,
this term does not describe the situation well, as it
represents mirroring around a vertical axis rather
than inversion around a horizontal axis. The general incidence of mirror-image arrangement is rare and
approaches 0.01% of the population. All body organs are in mirror-image position, so that the morphologically right lung is on the left side with the
inferior vena cava and liver major lobe, and the morphologically left lung, stomach, spleen, and descending aorta are on the right (Fig. 3.5a). Likewise,
within the heart, the morphologically right atrium
is left-sided, and the morphologically left atrium is
right-sided (Fig. 3.5b). Usually, the bowel is rotated so that it sits in a mirror-image position. When
a right-sided heart and its axis are found in a mirror-imaged atrial arrangement, the incidence of cardiac malformations is only slightly higher than in
the general population – of the order of 0.3-5% [9].

a

23

However, in one major fetal series, 12 out of 19 cases with situs inversus had structural cardiac malformations [10]. This is probably the consequence
of selected cases referred for fetal echocardiography
to a tertiary care center. Mirror image arrangement
was reported in a case with Turner’s mosaicism [11].
In 20% of cases, mirror-image arrangement is associated with Kartagener syndrome, an autosomal
recessive disease characterized by primary ciliary
dyskinesia, which leads to repeated sinus and pulmonary infections and reduced fertility in postnatal
life. Frequent pulmonary infections often result in
bronchiectasis, which predominantly affects the lower lungs [12].
In transverse sections of the upper abdomen, the
descending aorta is close to the spine and slightly to
the right of the midline. The inferior vena cava is anterior and slightly to the left. The stomach is on the
right, and the portal sinus curves to the left, where
the predominant liver lobe is located (Fig. 3.6). When
the left and right axis of the fetal body are not routinely assessed as a preliminary step in fetal scanning, this arrangement can be easily confused with
usual arrangement.

Left Isomerism (Polysplenia)
Heterotaxy is the definition commonly used to indicate an abnormal visceroatrial arrangement of the viscera that is different from usual or mirror-image
arrangement. Two types of heterotaxy can be recognized: left isomerism and right isomerism. The
term isomerism refers to the symmetrical development of organs that are normally asymmetrical,
which characterize heterotaxy syndromes. These syndromes include a wide range of cardiac, vascular, and
visceral abnormalities [12-18].

In individuals with left isomerism, both sides of
the body show left morphology, and some structures
normally found on the right are absent. Both lungs,
therefore, are usually bilobed, with long and hyparterial bronchi (Fig. 3.7a). There are frequently multiple spleens present, giving rise to the term “polysplenia” syndrome, but this is not a universal finding. The liver is a central structure with two
symmetric lobes, the inferior vena cava is interrupted in approximately 90% of cases, and venous blood
from below the diaphragm drains back to the heart
via the azygos or hemiazygos vein system, either or

25

CHAPTER 3 • The Visceroatrial Arrangement (Situs)
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R
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a

b

A
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Fig. 3.8 • The normal azygos vein (white arrowheads) in a normal heart and lung block ensemble seen from behind (a)
and from the right upper side (b). The azygos vein runs posteriorly and medial to the descending aorta then arches superiorly above the right bronchus to join the superior vena cava before its junction with the right atrium. AAO ascending aorta, AOA aortic arch, DAO descending aorta, E esophagus, InA innominate artery, LL left lung, LSA left subclavian
artery, SVC superior vena cava, RAA right atrial appendage, RB right bronchus, RJV right jugular vein, RL right lung,
RV right ventricle, T trachea

Fig. 3.9 • The inner surface of the two atria is
shown in a fetal heart with left isomerism; the
atrial appendage is hooked, with a narrow
junction with the atria on both sides. Because
both atria are morphologically left, the atrial
vestibule (white asterisk)
k shows a smooth surface bilaterally. There is an atrioventricular septal defect (black bracket),
t with large atrial and
relatively small ventricular component. Therefore, the crux cordis is absent. AA atrial appendage, mLA morphologically left atrium

both of which continue into the thorax to reach the
superior vena cava system (Fig. 3.8). The enlarged
azygos vein sits in paravertebral position always posterior to the descending aorta and can be identified
by ultrasound in the fetus [19]. The position of the
stomach and of the descending aorta is variable and
inconsistent with the identification of this situs type.
They can be located either to the left or right, on the
same side, or on opposite sides. The intestines are
almost always malrotated, although their precise position within the abdomen varies in each individual.
Within the heart, both atrial appendages are morphologically left. They are therefore narrow tubular

Fig. 3.10 • Transverse cross-sectional image of portal sinus in a 34-week gestational-age fetus with left isomerism (a). The
azygos vein sits posteriorly to the descending aorta close to the spine and slightly to the right of the midline. The stomach
is also on the right side. Diagram of transverse section of the upper abdomen in left isomerism (b). Because of their variable
positions, the azygos (or hemiazygos) vein and the descending aorta are represented on both sides of the midline. The stomach is not represented because its position is variable and inconsistent with identification of this type of situs. AzV azygos
vein, DAO descending aorta, HeV hemiazygos vein, PoV portal vein, S spine,
e St stomach, UV umbilical vein

In general, left isomerism has a better prognosis
because of the less severe associated cardiac defects.
However, the incidence of severe cardiac lesions is
higher in prenatally diagnosed cases [20].
In patients with polysplenia, biliary atresia may
be present. In fact, 10% of all patients with biliary
atresia also have polysplenia [21, 22]. Malrotation
anomalies of the intestines include a wide spectrum
that ranges from nonrotation to reversed rotation and
faulty peritoneal attachments. Duodenal atresia or
stenosis may also be present.
In transverse sections of the upper abdomen, the
inferior vena cava is nearly always interrupted, with
azygos or hemiazygos continuation. In these cases, the
venous channel lies in paravertebral position on the
same side of and posterior to the descending aorta. Due
to the symmetric liver lobes, the portal sinus often
shows an ambiguous way of branching (Fig. 3.10).

Right Isomerism (Asplenia)
Right isomerism is characterized by bilateral “rightness”. Consequently, both lungs are frequently trilobed
with short eparterial bronchi. The descending aorta and
inferior vena cava are commonly on the same side of
the abdomen, although both can be right- or left-sided,
and the inferior vena cava is located anterior to the
descending aorta. As in left isomerism, in right isomerism, the stomach appears to be randomly positioned on the right or left but can also appear central

in some instances, with a tubular shape. The stomach
and heart can both be located on the same or opposite sides (80% of cases in the Guy Hospital series)
[24]. The intestines are malrotated, and the liver is a
central structure with two symmetric lobes. As the
spleen is normally a left-sided organ, there is frequently complete absence of the spleen (asplenia),
although – again – this is not a universal finding (Fig.
3.11a). With respect to the heart, both atrial appendages
are morphologically of right type. The internal aspect
of both atria is rough, as the pectinate muscles extend
from the tip of the appendages around the entirety of
the atrioventricular junction (Fig. 3.11b).
Associated cardiac malformations are the rule in
right isomerism [25]. By definition, the pulmonary
veins always show anomalous connection, as there
is no morphologically left atrium for them to connect to. They usually join together into a confluence
behind the atria, which then drains anomalously below the diaphragm via a descending vein or to the
superior vena cava via an ascending vein. Rarely,
they drain directly to the atria or the coronary sinus.
Other common malformations include:
• abnormal heart position;
• bilateral superior vena cava;
• totally anomalous pulmonary venous connection
• atrioventricular septal defect, often unbalanced;
• double-outlet right ventricle or discordant ventriculoarterial connections;
• pulmonary-outflow-tract obstruction;
• abnormal ventriculoarterial connections.

Fig. 3.12 • Transverse cross-sectional view of the portal sinus in a fetus with right isomerism (a). The inferior vena cava
and descending aorta sit on the right side of the midline, with the inferior vena cava in anterolateral position. A tubular
stomach is slightly to the left of the midline. The liver shows two nearly symmetrical lobes with a T-shaped branching of
the portal sinus. These images could be mistaken for situs solitus by an inexperienced examiner. Diagram of transverse
section of the upper abdomen in right isomerism (b). Because of their variable position, the inferior vena cava and descending aorta are represented on both sides of the midline. The stomach is not shown because its position is variable
and inconsistent with identification of this type of situs. DAO descending aorta, IVC inferior vena cava, LLL left liver lobe,
PoV portal vein, RLL right liver lobe, S spine,
e St stomach, UV umbilical vein

In transverse sections of the upper abdomen, the
descending aorta and inferior vena cava lie on the same
side of the midline, either to the left or right. The inferior vena cava sits in anterolateral position relative
to the descending aorta. These two vessel can be either to the right or left of the midline. Due to the sym-

metric liver lobes, the portal sinus is ambiguous, often showing a T-shaped branching (Fig. 3.12). Right
isomerism can be difficult to differentiate from situs
solitus when the stomach is on the left and both great
vessels at the level of the diaphragm are not imaged
in a true transverse section.

Introduction
Although in most individuals two thirds of the heart
is in the left side of the chest, the heart can be unusually positioned. All cardiac positions can be described in terms of overall location of the heart and
orientation of its axis. The cardiac position and axis can be assessed by fetal echocardiography in the
four-chamber view. In this view, by tracing the sagittal and coronal planes through the center of the thorax, four quadrants are identified. In the normal individual, the left ventricle, most of the right ventricle, and the anterior part of the left atrium, lie in the
left anterior quadrant. A small part of the right ventricle and most of the right atrium fall in the right
anterior quadrant, and the posterior part of the left
atrium is in in the posterior quadrants (Fig. 4.1) [1].

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Fig. 4.1 • Cross-sectional four-chamber view of a normal 21week gestational-age fetus. The four quadrants, identified by
the sagittal and coronal planes (white dashed lines) traced in
the center of the thorax, are shown (see text for details.) LA left
atrium, LV left ventricle, RA right atrium, RV right ventricle, S spine

The axis of the heart refers to its long axis. The
orientation of this axis can be expressed as the angle between a line along the ventricular septum, directed toward the cardiac apex, and the midline sagittal plane of the thorax (Fig. 4.2). In the normal individual, the axis is oriented approximately 45° to
the left [2]. In hearts with one large and one rudimentary ventricle, the ventricular septum can be difficult to identify. In these cases, the cardiac axis coincides with the major axis of the large ventricle.
Regarding position, the heart can be left-sided (levocardia), central (mesocardia), or right-sided (dextrocardia) within the thorax. Rarely, it can be located outside the thorax (ectopia cordis). The orientation of the cardiac axis is independent from the
position of the heart. Therefore, for each heart posi-

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Fig. 4.2 • In this normal four-chamber view, the yellow arrow
is traced along the ventricular septum to indicate the axis of
the heart, with the arrowhead pointing toward the apex. The
normal range of the angle between the cardiac axis and the
midline sagittal plane (white dashed line) is indicated. LA left
atrium, LV left ventricle, RA right atrium, RV right ventricle, S spine

30

Echocardiographic Anatomy in the Fetus

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a

b

Fig. 4.3 • Two examples of different positions and axis orientations of the heart and how they can be described. a Central
heart, axis to the left. b Left-sided heart, axis to the right

tion, orientation of the axis can be to the left, to the
midline, or to the right and must be described separately (Fig. 4.3). Anomalies of the cardiac position
or axis can occur in isolation, although many anomalies alter both.
An abnormal cardiac position frequently coexists
with abnormal cardiac morphology. However, an abnormal heart position is not a disease per se and can
be found in an entirely normal heart. For example, a
right-sided heart is the normal situation in individuals with mirror-image visceroatrial arrangement.
Therefore, cardiac position and axis must be placed
in the context of a global assessment that takes into
account the visceroatrial arrangement, the segmental
analysis of the cardiac morphology, and the possible
presence of anomalies of organs within the thorax.
As stated, the cardiac position and axis can be assessed in the four-chamber view, whereas the visceroatrial arrangement can be defined in transverse
views of the upper abdomen (please refer to Chapters 3, 5, and 6).

Heart in the Left Side of the Chest (Levocardia)
As stated earlier, a left-sided heart with the axis pointing to the left is the normal pattern in individuals with
usual visceroatrial arrangement. However, even in
this setting, anomalies can occur. Pronounced rotation of the cardiac axis to the left has been described
in pulmonary valve stenosis (Fig. 4.4) and Ebstein’s
anomaly. Dilatation of the right atrium has been advocated as the cause of the rotational anomaly in
these cases. Leftward rotation of the cardiac axis may
also be observed in conotruncal malformation,
where the size of the cardiac chambers is usually nor-

A
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Fig. 4.4 • Four-chamber view in a 24-week gestational-age
fetus with critical pulmonary valve stenosis in usual arrangement. The heart is mostly in the left side of the chest, with
its axis ((yellow arrow
w) pointing to the left. However, the cardiac axis shows a pronounced leftward rotation, close to 85°
from the midline sagittal plane (white dashed line). DAO descending aorta, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, S spine

mal (Fig. 4.5). Overrotation during embryogenesis
has been hypothesized in axis deviation of these congenital heart diseases [3, 4]. However, abnormal cardiac axis is an inconstant finding and can be overlooked on routine examination. Only including assessment of the ventriculoarterial connections in
prenatal ultrasound screening will detect most
conotruncal anomalies.
A heart in the left side of the chest may show a
position excessively to the left. This may happen in

CHAPTER 4 • The Cardiac Position and Axis Orientation
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31

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Fig. 4.5 • Four-chamber view in a 27 week-gestational-age
fetus with tetralogy of Fallot in usual atrial arrangement. The
heart is mostly in the left side of the chest, with the cardiac
axis (yellow arrow) slightly overrotated to the left, approximately 70° from the midline sagittal plane (white dashed
line). DAO descending aorta, LA left atrium, LV left ventricle,
RA right atrium, RV right ventricle, S spine

Fig. 4.6 • Four-chamber view in a 23-week gestational-age
fetus with agenesia of the left lung. The cardiac axis (yellow
arrow) is normally to the left, approximately 30° from the
midline sagittal plane (white dashed line), but the heart is
displaced to the left, reaching the most lateral part of the
left hemithorax. The left atrium and ventricle are in close
contact with the thoracic cage (yellow arrowheads). The atrial arrangement is usual. LA left atrium, LV left ventricle,
RA right atrium, RV right ventricle, S spine

unilateral agenesia of the left lung, where the heart is
displaced toward the affected hemithorax (Fig. 4.6) [5].
Because a right-sided heart is normal in mirrorimage visceroatrial arrangement, if the heart is located
in the left side of the chest in this setting, it will be
frequently associated with congenital heart defects.

Heart in the Right Side of the Chest
(Dextrocardia)

Heart in the Middle of the Chest (Mesocardia)
This is the least common type of malposition observed in postnatal autopsic series [6, 7]. In decreasing order of frequency, a central heart has been
found in normal hearts and in congenitally corrected transposition (Fig. 4.7), complete transposition,
and double-outlet right ventricle. In our experience
(unpublished data), a central heart with apex pointing to the midline is a common cardiac finding in
hearts with tricuspid atresia (Fig. 4.8).
Anomalies of cardiac position of any type can occur in lung malformations [8, 9]. In cystic adenomatoid malformation (CAM), when the disease affects
both lungs, the heart can be in the central part of the
chest and appear compressed by the overdistended
lungs. Lung overdistension may occur also in laryngeal stenosis, as is seen in Fraser syndrome (Fig. 4.9).

Dextrocardia is a condition that includes a heterogeneous spectrum of hearts and in which the incidence of cardiac malformations varies according to
the cardiac situs. Two major fetal series on this type
of cardiac malposition have been published, reporting a high incidence of structural cardiac and extracardiac malformations [10, 11]. More rarely, a
right-sided heart has been found in association with
an abnormal karyotype [12, 13].
In usual atrial arrangement, the terms “dextroposition” and “dextroversion” have been used by
many authors to distinguish two different types of
hearts in the right side of the chest. The terms “levoposition” and “levoversion” have been used to indicate similar conditions in cases with mirror-image
visceroatrial arrangement.
Dextroposition has been used to refer to a translational problem of the heart that is displaced in the
right hemithorax but maintains a relatively normal
axis orientation to the left, that is, to the side expected
from the situs. In malpositions of this type, extracardiac malformations are common and often re-

32

Echocardiographic Anatomy in the Fetus

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b

a

Fig. 4.7 â&#x20AC;˘ Four-chamber view (a) and transverse view of the upper abdomen (b) in a 22-week gestational-age fetus with the
heart in the middle of the chest. Cardiac axis (yellow arrow) is nearly parallel to the midline sagittal plane (white dashed line).
This malposition occurred in the context of an atrioventricular and ventriculoarterial discordance and mirror-image visceroatrial
arrangement. Reversed position of the stomach and the great vessels (b) is seen. Mirror-image atrial arrangement occurred
in two out of 14 cases of atrioventricular discordance in our initial fetal series. Precise evaluation of cardiac connections in
this setting represents one of the most challenging tasks in prenatal diagnosis, with an increased risk of misinterpretation
and inappropriate counseling. DAO descending aorta, IVC inferior vena cava, mLA morphologically left atrium, mLV morphologically left ventricle, mRA morphologically right atrium, mRV morphologically right ventricle, S spine, St stomach

A

R

P

L

Fig. 4.8 â&#x20AC;˘ Four-chamber view in a 25-week gestational-age
fetus with tricuspid valve atresia. The heart is in central position within the chest with its axis (yellow arrow) pointing
to the midline (white dashed line). The atrial arrangement is
usual. LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle, S spine

sponsible for the abnormal location of the heart.
These malformations include space-occupying lesions within the thorax, such as diaphragmatic hernia (Fig. 4.10), cystic adenomatoid malformation of
the lung, and tumors of the lung or the mediastinum.
Congenital heart disease can be associated and must
be always ruled out. Left diaphragmatic hernia represents the typical example of extracardiac malformation that can cause cardiac malpositions of this
type. In up to 20% of cases, diaphragmatic hernia
can be associated with congenital heart disease,

which can be of every kind [14]. An associated cardiac defect is generally an indicator of poor prognosis [15]. In the majority of cases with left diaphragmatic hernia, cardiac dimensions in general
and the left heart chambers in particular are smaller
than normal. However, only a minority of cases develops a true hypoplastic left heart.
Dextroversion has been used to indicate a rotational problem of the heart, as though the cardiac axis had pivoted horizontally to the right around a superoinferior axis. In malposition of this type, the heart

CHAPTER 4 • The Cardiac Position and Axis Orientation

33

P
R
L
A

a

b

Fig. 4.9 • Four-chamber view (a) and the anatomic specimen of the opened chest (b) in a 22-week gestational-age fetus
with Fraser syndrome who underwent termination. Lung overdistension, due to laryngeal stenosis, caused compression
of the heart chambers, with impairment to the flow of the vena cava, increased hydrostatic pressure, and massive ascites.
The echocardiographic image shows a small heart in the middle of the thorax, squeezed by two overexpanded lungs.
The cardiac axis (yellow arrow) points to the left of the midline (white dashed line) in the setting of usual atrial arrangement. H heart, LA left atrium, LL left lung, LV left ventricle, RA right atrium, RL right lung, RV right ventricle, S spine

A
L
R
P

is located in the right side of the chest, with its axis pointing to the right, that is, to the opposite side
from that expected for the visceroatrial arrangement.
Although such a right-sided heart can rarely be normal (Fig. 4.11), the large majority of cases is associated with congenital heart disease. Among these,
the most common is a discordant atrioventricular connection (Fig. 4.12) [16, 17].
A diagram summarizing three common types of
dextrocardia is shown in Figure 4.13.
Trying to describe in a few words different
types of right-sided hearts, one can be tempted to
use short definitions such as dextroposition, dex-

Fig. 4.10 • Four-chamber view in a 33-week gestational-age
fetus with left diaphragmatic hernia. The heart is in the right
side of the chest but with the apex still pointing to the left
(yellow arrow) of the midline (white dashed line). Part of the
herniated stomach can be seen behind the heart. The left
atrium and ventricle are hypoplastic. DAO descending aorta, LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle, S spine, St stomach

troversion, pivotal dextrocardia, isolated dextrocardia, or secondary dextrocardia. However, these
definitions frequently do not apply to many conditions or can be simply equivocal. Cases shown
in Figures 4.11 and 4.12, for example, could both
fall into the definition of dextroversion, which
does not tell anything about the important differences between their structural morphology and
physiology.
Therefore, we agree with Prof. Robert Anderson’s
teaching [18] that the use of these term should be abandoned in favor of a purely descriptive segmental approach to the malformed heart.

34

Echocardiographic Anatomy in the Fetus
A

A
R

R

L

L
P

P

b

a

Fig. 4.11â&#x20AC;˘ Four-chamber view (a) and transverse section of the upper abdomen (b) in a 26-week gestational-age fetus. The heart
is located in the right chest with its axis (yellow arrow) to the right of the midline (white dashed line). The visceroatrial arrangement
is usual. Sequential analysis revealed an entirely normal heart, and no associated extracardiac anomalies were identified. DAO descending aorta, IVC inferior vena cava, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, PoS portal sinus, S spine

L

L

A

A

P

P

R

R

a

b

Fig. 4.12 â&#x20AC;˘ Four-chamber view (a) and transverse section of the upper abdomen (b) in a 32-week gestational-age fetus. The
heart is mostly located in the right chest with its axis (yellow arrow) pointing to the right of the midline (white dashed line).
The visceroatrial arrangement is usual. The atrioventricular connection is discordant, with the the atria being connected with
ventricles of opposite morphology. Discordant ventriculoarterial connection, ventricular septal defect, and pulmonary valve
stenosis are among associated cardiac defects in this case. DAO descending aorta, IVC inferior vena cava, LA left atrium,
mLV morphologically left ventricle, mRV morphologically right ventricle, RA right atrium, S spine, St stomach, UV umbilical vein

CHAPTER 4 • The Cardiac Position and Axis Orientation

a

b

35

c

A
R

L
P

Fig. 4.13 • Diagram simulating the transverse view of the upper abdomen and the four-chamber view in three different
types of hearts in the right side of the chest (dextrocardia). Right-sided heart associated with mirror-image visceroatrial
arrangement (situs inversus) (a). This type of dextrocardia has also been called “mirror-image dextrocardia”.Two other types
of dextrocardia with usual visceroatrial arrangement are shown (b, c). Right-sided heart with apex to the right (b). This
type could be defined as “dextroversion”. Note that the ventricle immediately behind the sternum is the morphologically left ventricle and not the morphologically right ventricle, as observed in a. The left atrium is elongated and bent to the
right to maintain its connection with the anterior ventricle. Right-sided heart is shown with the axis still pointing to the
left (c). This case has been called “dextroposition” and is usually secondary to space-occupying lesions within the thorax
(white asterisk). DAO descending aorta, IVC inferior vena cava, mLA morphologically left atrium, mLV morphologically left
ventricle, mRA morphologically right atrium, mRV morphologically right ventricle, S spine, UV umbilical vein

Isomerism of the Atrial Appendages and
Cardiac Position
Abnormal cardiac position has been observed in up
to 60% of cases with either form of isomerism. In
nearly one third of such cases, the heart is in the right

side of the chest. In up to 80% of cases with right
isomerism and 50% with left isomerism, the heart
and stomach are located on opposite sides of the
body. This finding can be easily detected by the obstetric sonographer during a routine examination and
should alert to the possibility of a visceroatrial anomaly of this type (Figs. 4.14, 4.15) [19].

36

Echocardiographic Anatomy in the Fetus
A

R

L

P

A

R

a

L

P

b

Fig. 4.14 • Four-chamber view (a) and transverse section of the upper abdomen (b) in a 21-week gestational-age fetus
with left isomerism. The stomach and the heart lie on opposite sides of the body. The heart is mostly in the left side of
the chest, but its axis (yellow arrow) shows a pronounced rotation to the left, being approximately 80° from the midline
sagittal plane (white dashed line). Azygos continuation of the inferior vena cava, common atrium, and atrioventricular septal defect are among the associated cardiac malformations. A atrium, AzV azygos vein, DAO descending aorta, mLV morphologically left ventricle, mRV morphologically right ventricle, S spine, St stomach

Once the laterality, visceroatrial arrangement, and
cardiac position of the fetus have been established,
the next step is to analyze the heart in a sequential segmental approach. Sequential analysis allows
description of all congenital heart malformations,
even the more complex ones, simply and unambiguously [1-3]. All hearts, whether normal or abnormal, can be assumed to comprise three major
segments and two connections between those segments. Each segment is usually partitioned into one
left-sided and one right-sided component. The three
segments are the atria, the ventricles, and the arterial trunks. The connections consist of the atrioventricular connection and the ventriculoarterial
connection. A fourth segment – the systemic and
pulmonary veins, and its connection – the venoatrial connection, must be assessed for a complete
segmental analysis. This is not discussed in this
chapter because of the great variability of these
structures.
In congenital heart malformations, the cardiac
structures may not always be in their expected location and may be connected in an abnormal sequence. Therefore, the atria and the ventricles
should be recognized by their anatomic structure and
not by their location, and thus the terms “morphologically left” and “morphologically right” should
be used instead of simply “left” and “right”. In practice, the heart should be evaluated by following the
direction of blood flow in order to assess the connection of the systemic and pulmonary veins, the
atria, the atrioventricular connection, the ventricles,
the ventriculoarterial connection, and the great arteries. Sequential examination must define morphology, position (relative and absolute), size, functional status, and state of septation (separation of the
right-sided from the left-sided structures) of a segment or a connection. Sequential analysis represents
a diagnostic fundamental basis for the clinician and
the pathologist.

Each atrium is usually composed of four basic parts:
(1) the venous component, receiving the systemic or
pulmonary venous return, (2) the vestibule, giving
access to the atrioventricular valve, (3) the septal surface, and (4) the appendage. When these parts are
considered in terms of constancy in malformed
hearts, it can be demonstrated that parts 1, 2, and 3
cannot be used as a defining criterion to identify the
morphologically right or left atrium. In fact, the venous return to the atria, the atrioventricular valves,
and the atrial septum are variable structures in abnormal hearts and can be totally lacking. On the other hand, the appendages are the most constant component of the atria [4]. Their shape, the morphology of their junction with the body of the atrium, and
the extent of the pectinate muscles within the appendage always show a morphologically right or left
pattern. The morphologically left atrial appendage is
tubular, hook-shaped, and has a narrow junction with
the body of the atrium. The internal surface of the
latter is smooth, as the pectinate muscles are restricted to the appendage. The morphologically
right atrial appendage is triangular, with a broad junction with the body of the atrium. On its internal aspect, it contains pectinate muscles extending around
the atrioventricular junction and reaching the crux
of the heart.
As already described in the dedicated chapter,
there are four possible arrangements of the atria. In
usual arrangement, the left-sided atrium is morphologically of left type, and the right-sided atrium is
morphologically of right type. In mirror-image
arrangement, all body organs are in mirror-image position. Therefore, within the heart, the morphologically right atrium is left-sided, and the morphologically left atrium is right-sided. In left isomerism, both
atrial appendages are morphologically of left type.
They are therefore narrow tubular structures, and the
interior aspect of both atria is smooth. In right isomerism, both atrial appendages are morphological-

40

Echocardiographic Anatomy in the Fetus

Fig. 5.1 â&#x20AC;˘ Diagram of the four different types of atrial arrangement and the correspondent section of the upper abdomen
showing the location of the descending aorta and the inferior vena cava

ly of right type. The internal aspect of both atria will
show pectinate muscles extending from the tip of the
appendages around the entirety of the atrioventricular junction.
Because the morphology of the atrial appendage
is very difficult to recognize directly on echocardiography, the atrial arrangement can be determined
indirectly from the location of the aorta and the inferior vena cava on transverse view of the upper abdomen (Fig. 5.1) [5].

The Ventricles
The ventricular mass is the cardiac segment that extends from the atrioventricular junction to the ventriculoarterial junction. A ventricle is an endocardial-lined chamber within the ventricular mass. Almost always, there are two ventricles in the
ventricular mass. Each ventricle usually consist of
three parts: (1) the inlet, (2) the apical trabecular,
and (3) the outlet components. Because the inlet and
outlet component can be missing, a rudimentary
ventricle may consist of only one or two parts. The
most constant part of the ventricles is therefore the

apical trabecular component. In the morphologically right ventricle, the apical region is characterized by a coarse trabeculation, whereas in the
morphologically left ventricle the trabeculation is
fine (Fig. 5.2). This myocardial characteristic can
be recognized even in ventricles in which only the
apical part is represented. The type of ventricular
trabeculation is generally recognizable by fetal
echocardiography.
Other characteristic features of the normal morphologically right ventricle include the presence of
tendinous cord attachments of the tricuspid valve to
the ventricular septum; a complete muscular outlet
supporting the pulmonary valve; a prominent septal
trabeculation, the so-called septomarginal trabeculation; and an infolded ventricle roof, the supraventricular crest, which causes discontinuity between the
atrioventricular and the semilunar valve. Most of
these features can be recognized on fetal echocardiography (Fig. 5.3).
As for the morphologically left ventricle, characteristic features are a smooth septal surface, generally without septal attachment of the atrioventricular valve, and continuity between the atrioventricular and semilunar valve (Fig. 5.4).

CHAPTER 5 • Principles of Segmental Analysis

a

41

b

Fig. 5.2 • The different character of the apical trabeculation of the two ventricles is shown in a cardiac specimen (a) and
in a corresponding echocardiographic view (b). The trabeculation is coarse in the morphologically right ventricle (mRV)
and fine in the morphologically left ventricle (mLV)

a

b

Fig. 5.3 • Morphologic characteristics of the right ventricle are shown in a fetal cardiac specimen (a) and in a corresponding
echocardiographic view (b). The inlet, apical trabecular, and outlet components are seen. The white arrowhead indicates
the supraventricular crest, separating the tricuspid valve from the pulmonary valve. The open black arrow points to the
septal insertion of the tricuspid apparatus, and the black dotted line indicates the septomarginal trabeculation with its
two limbs. AOV aortic valve, PT pulmonary trunk, PV pulmonary valve, RA right atrium, TV tricuspid valve

42

Echocardiographic Anatomy in the Fetus

a

b

Fig. 5.4 â&#x20AC;˘ Characteristics of the left ventricle are displayed in a specimen (a) and in a corresponding echocardiographic
view of a fetal heart (b). The inlet, the apical trabecular, and the outlet components are seen. These pictures demonstrate
how the septal surface of the left ventricle is free from cordal attachment of the mitral valve. The aortic (1) and mural (2)
leaflets of the mitral valve are seen. The white asterisk indicates the continuity between the aortic leaflet of the mitral
valve and the aortic valve. The anterolateral (3) and septal (4) leaflets of the tricuspid valve are seen, with their close relationship with the right side of the ventricular septum. AOV aortic valve, LA left atrium, MV mitral valve, TV tricuspid valve

The Arterial Trunks
As for the third segment, there are four possible types
of arterial trunks. The branching pattern usually allows their identification.
In the normal heart, the aorta originates in the center of the heart. The three sinuses of Valsalva in its
root support the aortic valve, and from two of them,
the coronary arteries originate. Whatever its connection with the ventricular mass, the aorta runs superiorly to form the aortic arch, where it gives origin to the brachiocephalic vessels: the innominate
artery, the left common carotid artery, and the left
subclavian artery (Fig. 5.5). Because of the caudocranial alignment of its major axis, the aorta can
be imaged on parasagittal planes of the fetal body.
Usually, the brachiocephalic vessels are more easily identified by fetal echocardiography than are the
coronary arteries, particularly in second-trimester
scans.
In the normal heart, the pulmonary trunk springs
from the infundibulum, where the three sinuses of
Valsalva support the pulmonary valve. The main pulmonary artery runs anteroposteriorly on a nearly horizontal plane and bifurcates early into the right and
left pulmonary arteries (Fig. 5.6). In the normal heart,
the main pulmonary artery connects to the descend-

ing aorta via the arterial duct. Because of the anteroposterior alignment of its major axis, the main
pulmonary artery and its proximal branches are therefore seen in transverse sections of the fetal thorax.
Two other types of arterial trunks can exist: a
common arterial trunk supplying all the pulmonary,
coronary, and systemic arteries, and a single great
artery connected to the heart, with no central pulmonary arteries. Usually, the pulmonary artery circulation is supplied from major collaterals from the
descending aorta (Fig. 5.7).

The Atrioventricular Connection
As to the connection between the atria and the ventricle, the type and the mode of connection are discussed here. The type of atrioventricular connections describes how the atrial myocardium is joined
or is not joined to the body of the ventricles. The
atrioventricular connection can be biventricular or
univentricular. Biventricular atrioventricular connections can be concordant or discordant. The atrioventricular connection is concordant when each
atrial chamber is connected with its appropriate ventricle. On the contrary, the atrioventricular connection is discordant when each atrium is connected
with the morphologically inappropriate ventricle

CHAPTER 5 • Principles of Segmental Analysis

a

c

a

43

b

Fig. 5.5 • The coronary and brachiocephalic arteries branching from the aorta are shown in a diagram (a) and in two
echocardiographic views of the fetal heart (b, c). The aortic
arch giving rise to the brachiocephalic vessel is seen in a
parasagittal view of the fetal thorax (b), whereas the proximal tract of the right coronary artery is seen in a slightly
modified five-chamber view (c). AAO ascending aorta, AOV
aortic valve, DAO descending aorta, InA innominate artery,
LCA left coronary artery, LCCA left common carotid artery,
LSCA left subclavian artery, RCA right coronary artery

b

Fig. 5.6 • The pulmonary trunk branching in the right and left pulmonary artery is shown in a diagram (a) and in a transverse echocardiographic view (b) of the fetal thorax. LPA left pulmonary artery, MPA main pulmonary artery, PV pulmonary
valve, RPA right pulmonary artery

44

a

Echocardiographic Anatomy in the Fetus

b

Fig. 5.7 â&#x20AC;˘ Diagram of a common arterial trunk (a) and a solitary arterial trunk (b)

(Fig. 5.8). Concordant and discordant atrioventricular connections may occur in usual or mirror-image arrangement of the atria.
When there is isomeric atrial arrangement, the atrioventricular connection cannot be described in terms
of concordance or discordance (Figs. 5.9, 5.10). In
atrial isomerism, in fact, half of the heart has concordant and half has discordant atrioventricular connections. When the atrioventricular connection is ambiguous, the three-dimensional structure of the ventricular mass must be described. One accepted
method is to determine the ventricular topology by
the right- or left-hand method. This method consist
of examining the morphologically right ventricle and
determining whether a right or left hand can be figuratively placed, with the palm upon the septal surface, so that the thumb is in the ventricular inlet and
the fingers in the outlet (Fig. 5.11).

Univentricular atrioventricular connection occurs
when the atria are connected with only one ventricle. The dominant ventricle, which may be morphologically left or morphologically right, is invariably associated with a rudimentary chamber of the
opposite ventricle. Rudimentary ventricles of right
morphology are nearly always in anterosuperior position, whereas rudimentary ventricles of left morphology are in posteroinferior position (Fig. 5.12).
More rarely, the dominant ventricle is a solitary ventricular chamber with indeterminate morphology.
Atrioventricular connection mode describes the
characteristics of the atrioventricular valves. There
may be two atrioventricular valves or a common
valve. One valve may be imperforated or totally absent when one atrioventricular connection is lacking.
In the setting of two atrioventricular valves, one may
be straddling, when its tension apparatus attaches on
both sides of the interventricular septum, or overriding, when its valvular orifice lies across the interventricular septum (Fig. 5.13). Straddling and
overriding frequently coexist. When more than 50%
of an overriding atrioventricular valve opens into the
opposite ventricle, then the atrioventricular connection becomes univentricular. This has major physiopathological and surgical implications.

The Ventriculoarterial Connection
Ventriculoarterial connection type describes how the
ventricles are connected to the great arteries. The
ventriculoarterial connection can be concordant, discordant, double outlet, or single outlet. Concordant
ventriculoarterial connections exist when the

Fig. 5.12 â&#x20AC;˘ Diagram showing the relative position between the dominant
and the rudimentary ventricle when
the latter is morphologically right (a) or
morphologically left (b). LV left ventricle, RV right ventricle

morphologically right ventricle is connected to the
pulmonary artery and the morphologically left ventricle is linked to the aorta. Ventriculoarterial discordance corresponds to the origin of the aorta from
the morphologically right ventricle and the pulmonary artery from the morphologically left ventricle (Fig. 5.14).
Double outlet exists when both arterial trunks
originate from one ventricle. This may be morphologically right, morphologically left, or indeterminate.
Double-outlet right ventricle is far more common
than the other two types. In double-outlet ventricles,
the relative position of the great artery is variable and

is the basis of the different physiopathologic patterns
in this cardiac malformation (Fig. 5.15).
Single outlet occurs when only one arterial
trunk is connected to the ventricles. This can be a
common arterial trunk, the aorta, or the main pulmonary artery when the other artery is atretic and
its connection with a ventricle is not recognizable
(Fig. 5.16).
The position of the great arteries can be defined
by describing the position of the aorta relative to the
pulmonary artery at the level of their semilunar
valves. In the normal heart, the position of the aortic valve is right posterior (Fig. 5.17).

Fig. 5.15 • Diagram showing two examples of double-outlet right ventricle with different position of the great
arteries: aorta posterior to the left (a),
and side-by-side aorta to the right (b).
AO aorta, mLV morphologically left
ventricle, mRV morphologically right
ventricle, PA pulmonary artery

Fig. 5.16 • Diagrams of single-outlet
ventriculoarterial connection to a
common arterial trunk (a), to the aorta (b), and to the pulmonary artery (c).
In a, the arterial trunk supplies the aorta, the pulmonary artery, and the coronary arteries. In b, the pulmonary
artery is retrogradely perfused by the
aorta through the arterial duct (white
asterisk).
k In c, the aortic arch, the ascending aorta, and the coronary arteries are retrogradely perfused by the
arterial duct (white asterisk)
k

PART II
Echocardiographic Projections
A Transverse Views of the Fetal Body

PART II
Echocardiographic Projections
A Transverse Views of the Fetal Body

CHAPTER

6

The Transverse Views of the Upper
Abdomen

Introduction

The Umbilical Cord Insertion

This series of transverse sections of the fetal body
will be not discussed in detail here. The reader should
refer to books and papers dealing with this subject.
Among these sections, the portal sinus view holds a
crucial role, not only because it is close to the section used for biometry of the upper abdomen, but also because it is crucial in the assessment of the visceroatrial arrangement. These views can be the starting point in Doppler flow assessment of major veins
of the fetal circulatory system, such as umbilical vein
and ductus venosus and suprahepatic veins [1-8].

In this section, we see the junction of the umbilical cord with the anterior abdominal wall. The inferior vena cava and the abdominal aorta sit within the midline between the two psoas muscles, with
the aorta toward the left. This level cuts across the
crest of the iliac bones, below the level of the liver, and the bowel is seen filling the abdominal cavity (Fig. 6.1).

At a slightly more cranial level from its insertion,
the umbilical vein is seen in cross section running
cephalad immediately behind the anterior wall of the
abdomen. The lower part of the right lobe of the liver is seen in cross section, with bowel filling the left
side of the abdomen. Both kidneys are seen in cross
section sitting on either side of the inferior vena cava and the abdominal aorta (Fig. 6.2).

This is a transverse view of the upper abdomen, obtained above the level of the falciform ligament,
showing the confluence of the umbilical vein with
the left portal vein. This confluence is seen taking
an anteroposterior course, curving smoothly toward
the right. At the most posterior portion of this curve,
the very first part of the ductus venosus can often be
seen. The stomach lies on the left side of this view.
The abdominal aorta is located posteriorly, close to
the spine and to the left of the midline. The inferior
vena cava is located more anteriorly and slightly to
the right of the midline. The aorta and the inferior
vena cava at this level are of similar size (Fig. 6.4).
On ultrasound, the portal sinus view is close to the
section commonly used for biometry of the upper abdomen and is crucial in the assessment of the visceroatrial arrangement (Fig. 6.5).
In transverse section of the fetal abdomen, the inferior vena cava and aorta are seen at right angle with
the ultrasound beam. Because of the unfavorable insonation angle, the flow is difficult to see in these
vessels, and more commonly, only the abdominal

The Mid Liver
A transverse section across the mid liver shows the
larger right and the smaller left lobes. The umbilical
vein is now seen within the falciform ligament running posteriorly away from the anterior abdominal
wall. In contrast, the inferior vena cava moves anteriorly away from the spine and is slightly increasing in size. Both adrenal glands are seen in cross section, as is the upper pole of the kidney on the left.
The duodenum and distal part of the stomach are seen
more centrally (Fig. 6.3).

a
Fig. 6.4 • Transverse section of the fetal upper abdomen at the level of the portal sinus (a). The confluence of the umbilical vein into the portal vein is displayed, curving smoothly toward the right. The very first part of the ductus venosus is indicated. The size of the inferior vena cava and the descending aorta is very similar at this level. Part of the stomach is seen
on the left side. The section level is indicated on the fetal body (b). AG adrenal gland, DAO descending aorta, VD venous
duct,
t IVC inferior vena cava, LLL left liver lobe, PoV portal vein, S spine,
e RLL right liver lobe, St stomach, UV umbilical vein

54

Echocardiographic Anatomy in the Fetus
A

R

A
L

R

P

a

L
P

b

Fig. 6.5 â&#x20AC;˘ Cross sectional (a) and color flow mapping (b) echocardiographic views of the portal sinus in a normal 22-week
gestational-age fetus. The portal vein and the inferior vena cava are not coding in color because of the unfavorable insonation angle and the low velocity of blood flow. The umbilical vein and the descending aorta are coding in color, thanks
to the better insonation angle of the vein and the higher velocity of the artery (b). AG adrenal gland, DAO descending
aorta, IVC inferior vena cava, PoV portal vein, S spine,
e St stomach, UV umbilical vein

aorta is coding in color (Fig. 6.5b). With a very lowscale setting, it is possible to see the lumen of the
two vessels coded in different colors because of the
opposite direction of their flow (Fig. 6.6).
Because of its upward and posteriorly oriented
course, the ductus venosus can be regularly visualized in sagittal sections of the fetal body. In transverse
sections of the fetal body, its narrow isthmic entrance

from the portal sinus can be difficult to identify on
cross-sectional examination. By using color flow
mapping with a low-scale setting, the preorificial acceleration of blood at the entrance of the ductus venosus is easily recognized. When the portal sinus section is acquired with the transverse approach, the
blood flow can be seen inside the portal vein because
it is more parallel to the ultrasound beam (Fig. 6.7).

The Infracardiac Vena Cava
This section shows the very distal portion of the inferior vena cava just before its junction with the floor
of the right atrium. At this level, the size of the vena
cava is larger and its position is more anterior than
in caudal sections. This is because the inferior vena cava has already received the flow of the umbilical and suprahepatic veins. Due to the domeshaped conformation of the diaphragm, when this
section is truly horizontal, it shows both abdominal
and thoracic structures at the same time. In fact, the
upper parts of the right and left lobes of the liver
are seen to either side of the caval orifice. Anteri-

orly, the inferior part of the ventricles are seen and,
posteriorly, the inferior portion of the lower lobes
of the lungs. The esophagus sits between the descending thoracic aorta and the inferior vena cava
(Figs. 6.8, 6.9).

The Suprahepatic Veins
Slightly caudal to the section of the infracardiac
vena cava, a transverse section of the confluence
of the suprahepatic veins can be obtained. This confluence gives a stellate appearance, the so-called
“hepatic star”, to the cross section of the inferior
vena cava (Fig. 6.10).

56

Echocardiographic Anatomy in the Fetus

A
R

L
P

b

a
Fig. 6.8 â&#x20AC;˘ Morphologic section through the fetal upper abdomen at the level of the infracardiac portion of the inferior vena cava (a). Anteriorly, the inferior portion of the ventricles is seen encased in the pericardium (arrowheads). Because of
the dome shape of the diaphragm, a section of the upper part of the right and left lobes of the liver is seen, with the section of the inferior lobes of the two lungs posteriorly. The section level is indicated on the fetal body (b). DAO descending
aorta, E esophagus, IVC inferior vena cava, LL left lung, LLL left liver lobe, RL right lung, RLL right liver lobe, S spine

Fig. 6.10 • Transverse section of the confluence of the suprahepatic veins in a normal 25-week gestational-age fetus. On
cross-sectional examination (a), the confluence of the suprahepatic veins gives a stellate appearance, the so-called “hepatic star,” to the cross section of the inferior vena cava. Color flow mapping of the same section (b). The low-scale setting highlights the flow in the suprahepatic veins. On moving images, the blue pulsatile flow, in the center of the image,
is a phantom of the flow of the inferior vena cava (white asterisk).
k DAO descending aorta, E esophagus, IVC inferior vena
cava, Li liver, LL left lung, RL right lung, S spine, ShV suprahepatic vein

Because the diaphragm in the fetus is at a higher level within the chest, making the heart more horizontal than it is after birth, the four-chamber view of
the heart lies closer to a transverse section of the fetal thorax just above the diaphragm (Fig. 7.1) [1].
This view is easily obtained from a transverse plane
of the upper abdomen by tracing the inferior vena
cava to the right atrium and then angling the transducer slightly cranially until the four chambers are
visualized.

In a transverse section of the thorax (Fig. 7.2), the
morphologically right ventricle is the most anterior
chamber closest to the thoracic wall and can be recognized by its blunted apex. The left ventricle is in
posterior position and has an ellipsoidal shape. The
left atrium is the most posterior chamber, closest to
the spine and the descending aorta. On closer view
(Fig. 7.2b), the smooth endocardial surface of the
left atrium is clear, whereas the right atrium shows
extensive pectinate muscles branching from the ter-

S
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a

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Fig. 7.1 â&#x20AC;˘ Level of the four-chamber view on the fetal body (a) and on a heart (b) diagram. The diagram demonstrates
how the plane of this view lies along the long axis of the heart and perpendicular to the inlet of the interventricular
septum. In the classical four-chamber view, the tricuspid valve and the mitral valve can be seen but not the aortic
valve and the pulmonary valve, which lie on superior planes. AoV aortic valve, MV mitral valve, PV pulmonary valve,
TV tricuspid valve

60

Echocardiographic Anatomy in the Fetus
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Fig. 7.2 • In this specimen, the fetal thorax has been sectioned in a simulated four-chamber view (a). The same specimen
magnified for greater anatomical detail (b). The septal leaflet of the tricuspid valve ((yellow arrow
w) attaches to the atrioventricular junction more apically than the aortic leaflet of the mitral valve (white arrow),
w which is effectively inserted
to the underside of the atrial septum. The yellow arrowhead indicates the eustachian valve, which is seen anteriorly and
to the right of the orifice of the inferior vena cava (white cross), whereas the white arrowhead indicates the flap valve of
the foramen ovale, which forms its left posterior border and arches into the left atrium. Posteriorly, the left and right pulmonary artery joining the left atrium are displayed. The descending aorta, the esophagus, the bronchus, and the pulmonary artery of the lower lobe of the right lung are seen in between. B bronchus, CD crista dividens, DAO descending
aorta, E esophagus, LA left atrium, LPV left pulmonary vein, LV left ventricle, MV mitral valve, PA pulmonary artery, RA right
atrium, RPV right pulmonary vein, RV right ventricle, S spine, SVC superior vena cava, TC terminal crest, TV tricuspid valve

minal crest. The posterior portion of this latter chamber is smooth and receives the superior vena cava.
The septal leaflet of the tricuspid valve attaches to
the atrioventricular junction more apically than does
the aortic leaflet of the mitral valve, which is effectively inserted to the underside of the atrial septum. This results in the so-called “offsetting”, or
“differential insertion”, of the atrioventricular valves.
The atrioventricular valves together with the atrial
and ventricular septum meet in the center of the
heart, forming an offset cross known as the “crux
of the heart.” In the normal heart, the two atrioventricular valves are therefore separated and
nearly equal in size. The left and right lower pulmonary veins join the back of the left atrium to either side of the esophagus and the descending aorta. The inferior vena cava is seen entering the floor
of the right atrium, with a small portion of the interatrial septum overriding it. Because of its overriding, this upper portion of the atrial septum is
called crista dividens, which in Latin means “the
crest which divides.” This verb refers to the flow
coming from the inferior vena cava. The image depicts how the most posterior and leftward portion
of the inferior caval flow, which brings the most oxygenated blood coming from the venous duct and the

placenta, is diverted by this crest into the left atrium. The eustachian valve is seen anteriorly and to
the right of the orifice of the inferior vena cava,
whereas the flap valve forms its left posterior border, arching into the left atrium. A recent review has
been published illustrating many aspects of normal
and abnormal anatomy of the fetal heart and updating classical concepts of cardiac embryology [2].

The Normal Echocardiogram – 2D
The four-chamber view can be obtained echocardiographically with two basic approaches to the
fetal thorax: apical (Figs. 7.3, 7.4) or transverse
(Fig. 7.5). To ensure that this section is truly horizontal, one complete rib and no abdominal content should be imaged [3] (Fig. 7.3). In the fourchamber view, the examiner should identify the following features:
• Two atrial chambers of nearly equal size. The left
atrium should be the most posterior chamber and
closest to the spine. The right atrium is in contact with the right lung. Both atria connect with
the respective ventricle via an atrioventricular
valve.

61

CHAPTER 7 • The Four-Chamber View

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Fig. 7.3 • Cross-sectional apical view in a normal 21-week gestational-age fetus (a) and a corresponding diagram (b). This
section is considered suitable when the entire thorax is seen, there is a complete rib (yellow
(
open arrowheads), and no
abdominal content. The spatial relationship of the heart chambers inside the chest is illustrated. DAO descending aorta,
LA left atrium, LV left ventricle, MB moderator band, RA right atrium, RV right ventricle, S spine

Fig. 7.4 • Apical view in a normal 23-week gestational-age
fetus. The morphologically right ventricle is in anterior position and characterized by the moderator band and a lower insertion of the tricuspid valve into the ventricular septum. The white cross indicates the crux of the heart, where
the atrial septum fuses with the ventricular septum. The white
closed arrowhead indicates the atrioventricular septum,
which is delimited by the lower annular insertion of the tricuspid valve relative to the mitral valve. The open arrowheads
indicate the flap of the oval fossa arching inside the left atrium. The left and right inferior pulmonary veins are seen entering the posterior portion of the left atrium on either side
of the descending aorta. DAO descending aorta, LPV left pulmonary vein, MB moderator band, MV mitral valve, RPV right
pulmonary vein, SP septum primum, TV tricuspid valve

• Two ventricular chambers of nearly equal size and
thickness. The morphologically right ventricle
should be the most anterior chamber, lying immediately behind the anterior chest wall. The
morphologically right ventricle can be recognized
by its coarse trabeculation including a muscle
bundle, the moderator band, which transverses the
ventricular cavity and gives a characteristic
blunted appearance to its apex. The left ventricle
lies between the right ventricle and the left lung.
The morphologically left ventricle is finely trabeculated, and its apex is normally free from muscle bundles so that the apical part of the ventricular cavity is better represented in the four-cham-

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ber view (Fig. 7.3, 7.4). On the moving images,
the two ventricles should contract equally. In the
second trimester, the two atria and ventricles appear equal in size, but in the last trimester, a certain degree of dominance of the right chambers
is common [4-7].
• Two atrioventricular valves that can be seen to
open equally and with similar annular size. The
mitral valve on the left side and tricuspid valve
on the right side meet the atrial and ventricular
septa at the crux of the heart in an offset cross
appearance. This offset is due to insertion of the
tricuspid valve annulus slightly lower into the
ventricular septum than the mitral valve (Fig. 7.4).

62

Echocardiographic Anatomy in the Fetus

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Fig. 7.5 • Transverse view in a normal 34-week gestational-age fetus (a). Transverse view better represents the structure
of the atrial septum, because it is oriented at right angle relative to the ultrasound beam. Opening of the foramen ovale
in the middle of the atrial septum and the foraminal flap (open arrows) arching inside of the left atrium. On color flow
mapping with low scale setting (b), the normal right to left flow at the level of the foramen is visible in blue. The Niquist
limit was 20 cm/s. DAO descending aorta, LA left atrium, LV left ventricle, OF oval fossa, RA right atrium, RPV right pulmonary vein, RV right ventricle, S spine

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• The atrial septum should appear intact in the small
portion above the atrioventricular valves where
it fuses with the ventricular septum at the crux
of the heart (Figs. 7.4, 7.5). A normal opening,
the foramen ovale, occupies the middle third of
the atrial septum and is guarded by a thin membrane, the foraminal flap, which flickers into the
body of the left atrium.
• The interventricular septum should appear intact.
• With slight probe manipulation, the right and left
venoatrial connection can be assessed. The two in-

Fig. 7.6 • Cross-sectional view, obtained with slight caudal
tilt from the classical four-chamber view, of the inferior
venoatrial connection of the right atrium. The inferior vena
cava and the coronary sinus connect with the floor of the
right atrium. The cavity of the left atrium is not visualized.
CS coronary sinus, DAO descending aorta, IVC inferior vena
cava, LV left ventricle, RA right atrium, RV right ventricle,
S spine

ferior pulmonary veins are seen in the four-chamber view entering the back of the left atrium on either side of the descending aorta (Fig. 7.4). With
caudal angulation from the classic four-chamber
view, the ostium of the inferior vena cava appears
on the floor of the right atrium close to the inferior part of the interatrial septum (Fig. 7.6). Immediately posterior to the left atrioventricular junction,
the coronary sinus are seen entering the inferior portion of the right atrium. Because the coronary sinus is a structure coursing outside the heart along

CHAPTER 7 â&#x20AC;˘ The Four-Chamber View
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b

Fig. 7.7 â&#x20AC;˘ Circumferences (a) and areas (b) of the heart (C)
C and the thorax (TT) can be determined at the level of the fourchamber view

the left posterior atrioventricular groove, this vessel is visualized when the scanning plane is immediately inferior to the cavity of the left atrium.
Therefore, the cavity of the left atrium and the orifice of the mitral valve cannot be imaged at the
same time with the coronary sinus in horizontal sections (Fig. 7.6).

Dimensions of the Heart
The ratio of the size of the heart to that of the thorax
is a useful index of cardiac disease with heart failure
in both pediatric and adult cardiology. In the fetus, the
cardiothoracic (C/T) ratio has been proposed as a useful prognostic tool, easily obtained, in structural and
functional heart disease at risk to develop heart failure. The circumference of the heart and the circumference of the thorax can be measured and express as
ratio (C/T circumference ratio). A cross-sectional view
is suitable for this measurement when the entire thorax is seen and includes a good four-chamber view, a
complete rib, and no abdominal content (Fig. 7.7). The
C/T circumference ratio is rather constant, with a mean
value of 0.45 at 17 weeks and 0.50 at term [3]. Alternatively, one can calculate the ratio of the cardiac
and thoracic area (C/T area ratio). This ratio also is
fairly constant, with normal values between 0.25 and
0.35 throughout pregnancy [8]. When the C/T ratio is
abnormal, it is important to distinguish an enlarged
heart in a normal sized thorax from a normal sized

heart in a small thorax. This distinction can be obtained
by comparing the measured circumference of the chest
with the age-related normal values.

Measurement
The four-chamber view represent one of the basic
echocardiographic projection for measurement of
chamber size and ventricular wall thickness. Because
of its high frame rate and time resolution, M-mode
tracing (Fig. 7.8) is the most accurate method not only for these measurements but also for valve and wall
motion and is a useful tool in assessing cardiac arrhythmias [9]. Nevertheless, M-mode measurements
must be obtained with the ultrasound beam oriented at right angle to the structures to be measured. Because this orientation is difficult and sometimes impossible to obtain, the application of M-mode in the
fetus is limited.
Alternatively to M-mode tracing, fairly accurate measurements can be obtained from two-dimensional (2D) images, and this method has replaced the M-mode method in practice. Although
good images can be obtained with different cardiac orientation, the transverse four-chamber view
is recommended because with this orientation, the
ventricular walls, the interventricular septum, and
their endocardial surfaces are imaged at right angle with the ultrasound beam, with better resolution (Figs. 7.9, 7.10).

64

Echocardiographic Anatomy in the Fetus

a

Fig. 7.8 â&#x20AC;˘ End-diastolic (d) and end-systolic (S) transverse diameter of the left ventricle measured by M-mode tracing. The
upper part of this figure depicts how cross-sectional examination is utilized to identify the heart chambers in a transverse four-chamber view and to align the M-mode cursor perpendicular to the structures of interest. The cursor is placed
apically to the atrioventricular valves, and measurements are
performed from endocardial to endocardial surface. The diastolic diameter is taken at the end of diastole when the ventricular width is largest. This event coincides with the closure
of the atrioventricular valves (dashed line). The systolic diameter (s) is taken at the end of systole when the width of
the ventricle reaches its minimum, before the atrioventricular valves open. White open arrows indicate tricuspid valve
opening. LV Left ventricle, RV right ventricle

b
Fig. 7.9 â&#x20AC;˘ End-diastolic (a) and end-systolic (b) frame in a
transverse view. The yellow segments indicate where measurements of the width of the left and right ventricles are
taken. LA left atrium, LV left ventricle, RA right atrium, RV right
ventricle, S spine

Fig. 7.10 â&#x20AC;˘ The same end-diastolic frame as in Figure 7.9.
Measurements of the thickness of the left and right ventricular walls and of the interventricular septum (yellow segments). Of note, measurements of wall thickness and ventricular diastolic diameter are both taken close to the base
of the heart, just below the orifice of the atrioventricular
valves. The endocardial-to-endocardial method is utilized to
measure the cavities, and the endocardial-to-epicardial surface to measure ventricular-wall thickness. LA left atrium, LV
left ventricle, RA right atrium, RV right ventricle, S spine

Conversely to ventricular diameters and wall
thickness measurement, assessment atrioventricular
valve size will be obtained at the best in apical fourchamber view, because the plane of the atrioventricular valves is perpendicular to the ultrasound beam.
Moreover, the apical four-chamber view is better for measuring the long-axis diameter of both atria
and ventricles (Fig. 7.11) [10-14].

Ventricular Function
As in the pediatric population, segmental abnormalities of ventricular wall motion are very rare in the fetus. Therefore, some indices of global ventricular performance derived from linear dimensions can be used
as reliable estimates of left ventricular performance.
The ventricular fractional shortening (FS) is most
widely used among these indices, because it requires
two measurements that are quick and easy to obtain
FS = (EDD – ESD) / EDD
where EDD is the ventricular width at the end of diastole and ESD is the ventricular width at the end of

systole. Ventricular FS is often referred to as a percentage rather than a fraction. In general, the diameter of both the right and the left ventricles should
shorten more than 28%. Serial assessment of this index can be useful in following individual patients at
risk for developing fetal heart failure [15, 16].

The Normal Echocardiogram –
Color Flow Mapping and Pulsed Doppler
The Atrioventricular Valves
When the four-chamber view is obtained with apical
orientation, the inflow of both ventricles is parallel to
the ultrasound beam. Therefore, this approach is ideal for assessing the flow of the mitral and tricuspid
valves. When carrying out a pulsed Doppler inflow
study of the verticles, the sample volume is to be positioned on the ventricular side of the atrioventricular
valves immediately distal to their leaflets and parallel to the flow direction. The Doppler flow profile of
the mitral and tricuspid valves is similar, with a diastolic pattern characterized by two peaks: the first one

66

Echocardiographic Anatomy in the Fetus

a

b

Fig. 7.12 • Pulsed Doppler tracing of normal mitral (a) and tricuspid (b) valves in a 22-week gestational-age fetus. The
color flow mapping panels show that both tracings are obtained from an apical four-chamber view. The sample volume
position for each valve is displayed. A A wave, E E wave

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Fig. 7.13 • Pulsed Doppler tracing from the inflow–outflow of the left ventricle (a). The biphasic flow above the baseline
is the normal transmitral flow. The monophasic flow below the baseline (yellow open arrows) is the outflow from the left
ventricle and must not be mistaken for tricuspid regurgitation. Position of the sample volume for Doppler assessment
of the inflow–outflow of the left ventricle (b). A A wave, E E wave

(E wave) represents the passive ventricular filling as
the valve opens in the first part of diastole, whereas
the second (A wave) corresponds to the active ventricular filling during atrial contraction (Fig. 7.12).
These two peaks are well defined when the heart rate
is in the normal ranges, but they merge into each other for heart rates over 160-170 beats/min [17, 18].
In a normal atrioventricular valve, there should
be no backflow into the atria during systole. However, when examining the mitral valve, the sample
volume may find itself near the left ventricular outflow. Therefore, outflow toward the aorta may be
recorded during systole and must not be mistaken for
a mitral regurgitation (Fig. 7.13). This position of the

Doppler sample can be intentionally obtained for fetal cardiac rhythm assessment.
In contrast to postnatal life, in the normal fetus,
the E-wave is smaller than the A wave. This is due
to the reduced compliance of the fetal ventricular myocardium. Therefore, most ventricular filling takes
place in the second part of the diastole and is dependent on the regular atrial contraction. This explains why the loss in the regular sinus rhythm may
seriously compromise the fetal cardiac performance.
The atrioventricular valve velocities of the E wave
increase throughout gestation with values of 25 cm/s
at 16 weeks’ gestation and 45 cm/s at term for the
mitral valve and 30 cm/s and 50 cm/s for the tricuspid

CHAPTER 7 • The Four-Chamber View

67

Fig. 7.14 • Mitral and tricuspid valve Doppler
tracing obtained in the same patient from apical four-chamber view. Both tracings are represented with the same scale gain. The time velocity integral of the tricuspid valve flow is
slightly higher than that of the mitral valve and
is due to the larger output of the right ventricle in the fetal circulation

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Fig. 7.15 • Color flow mapping of the apical view from ventral (a) and dorsal (b) approach: diastolic frames. The atrioventricular valve shows equal width of the flow filling the ventricles. The asterisk indicates a bridge of color flow over
the inlet ventricular septum, simulating a defect at this level. This is a common artefact due to a high color gain setting.
The atrial or ventricular septum should be orthogonal to the ultrasound beam to investigate for defects in this region.
The different color of the flow in the two pictures indicates the opposite direction of the flow relative to the ultrasound
source. LA left atrium, LV left ventricle, RA right atrium, RV right ventricle

valve at the same gestational ages. The A wave shows
a relatively constant velocity or a mild increase during gestation, with values of 45 cm/s for the mitral
valve and 50 cm/s for the tricuspid valve.
The reason the E-wave velocity increases more
than that of the A wave is believed to be due to the
diastolic “maturation” of the ventricles during gestation. The ratio between the peak velocity of the
E and A waves on Doppler spectrum (E/A ratio)
is about 0.5 at the 16th week of gestation and is
around 1 near term. The slightly higher flow velocity through the tricuspid valve is mainly due to
the larger output of the right ventricle in the fetal
circulation (Fig. 7.14) [19].
Color Doppler is an integral part of the evaluation of the fetal heart in specialized centers and can

increase the speed and accuracy of the examination
[20-26]. Its use during a routine obstetrical scan of
the fetal heart is controversial.
In the normal fetus, color flow mapping evaluation in the four-chamber view shows equal and nonaliased flow through the atrioventricular valves in diastole (Fig. 7.15). In systole, there should be no evidence of regurgitation of the atrioventricular valves.
With high-resolution equipment, it is quite
common to detect a trivial jet of tricuspid regurgitation limited to a couple of frames in early systole
(Fig. 7.16) [27, 28].
In the four-chamber view, color Doppler is particularly useful to detect atrioventricular valve disfunction and tricuspid regurgitation in particular.
Semiquantitative assessment of the severity of re-

68

Echocardiographic Anatomy in the Fetus

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Fig. 7.16 • The heart is seen in the apical view. Color flow mapping is shown in three consecutive systolic frames. In this
early systolic frame (a), the yellow arrow indicates a tiny jet of physiologic tricuspid regurgitation. The regurgitant jet has
already stopped when the ejection phase into the aorta begins (b). Blue represents the flow in the left ventricular outflow tract toward the aorta (white arrow). No regurgitation is seen in this frame (c) at the end of the systole. LA left atrium, LV left ventricle, MV mitral valve, RA right atrium, RV right ventricle, S spine, TV tricuspid valve
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gurgitation of the atrioventricular valves is usually obtained on the basis of the spatial extension of the regurgitant signal by color flow mapping and atrial size.
When an area of regurgitation or a stenotic jet is iden-

b

Fig. 7.17 • Apical view (a) in 33-week gestational-age fetus
with Ebstein’s malformation of the tricuspid valve. The yellow arrow indicates apical displacement of the septal leaflet
of the tricuspid valve. Color flow mapping systolic frame (b)
showing a jet of significant tricuspid regurgitation that originates in the body of the right ventricle at the site of coaptation of the tricuspid leaflets. Continuous Doppler tracing
(c) of the regurgitant jet with a peak velocity around 3 m/s.
aRV atrialized right ventricle, DAO descending aorta, LA left
atrium, LV left ventricle, MV mitral valve, RA right atrium, RV
right ventricle, S spine, TV tricuspid valve

tified, color flow imaging is very helpful for aligning the Doppler cursor to assess velocities and estimated gradients across these valves. Figures 7.17-7.19
illustrate cross-sectional, color flow, and Doppler

CHAPTER 7 â&#x20AC;˘ The Four-Chamber View

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tracings obtained in the four-chamber projection in
some congenital heart diseases with disfunction of the
atrioventricular valve.

The Pulmonary Veins
The four-chamber view allows the best beam-flow
alignment for the Doppler study of the pulmonary
veins. Transverse or apical four-chamber views are
utilized, depending on fetal presentation and the vein
under study. It is often difficult to recognize the pulmonary veins on two-dimensional examination,
whereas they are more easily evidenced by color
Doppler with the low-scale setting. Color flow mapping facilitates correct alignment and positioning of
the sample volume of pulsed Doppler that is to be

69

b

Fig. 7.18 â&#x20AC;˘ Four-chamber views obtained from a left paravertebral approach in a 34-week gestational-age fetus with
severe mitral valve regurgitation. There is a severe dilatation
of the left atrium (a), and the atrial septum is displaced to
the right. On color flow mapping (b), a wide regurgitant jet
is seen due to lack of systolic coaptation of the mitral leaflets.
Mild regurgitation of the tricuspid valve is also present. The
cursor line is aligned for continuous Doppler assessment of
the jet. Doppler tracing (c) of mitral regurgitation. The mitral inflow is represented below the baseline, whereas the
regurgitant flow is above. The peak velocity of the jet is relatively low (2.66 m/s), indicating an impaired left ventricular function for a fetus of this advanced gestational age. LA
left atrium, LV left ventricle, MV mitral valve, RA right atrium,
RV right ventricle, TV tricuspid valve, S spine

placed in the terminal part of the veins, just before
their junction with the left atrium. While examining
pulmonary vein flow, it is advisable to limit the box
of the color Doppler to the posterior portion of the
left atrium to avoid an unclear, confused image
caused by the high-velocity flow of the ventricles
(Fig. 7.20).
The color Doppler profile of the pulmonary
vein flow reflects the variations in pressure in the
left atrium. As is observed in the vena cava, two
anterograde flow peaks are present, one systolic
and one protodiastolic. Although the velocity of
the systolic peak may be higher than the diastolic
peak, the difference is relatively modest or absent
in most patients. During atrial contraction, the flow
is seen to cease or a short inversion is observed
(Fig. 7.21).

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Echocardiographic Anatomy in the Fetus
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Fig. 7.19 â&#x20AC;˘ Four-chamber view (a) obtained from the right
chest approach in a fetus with mitral valve stenosis. The
dominance of the right heart chambers is abnormal for gestational age. The mitral annulus is small, and the valve
leaflets look dysplastic. The color flow diastolic frame (b)
shows a narrow and accelerated flow through the mitral
valve, whereas that of the tricuspid valve is wider and laminar. Pulsed Doppler tracing (c) of the accelerated mitral
valve flow. Despite the less than ideal alignment of the cursor line, the A wave peak velocity is high and close to 1.5 m/s.
CS coronary sinus, LA left atrium, LV left ventricle, MV mitral
valve, RA right atrium, RV right ventricle, S spine, TV tricuspid valve

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Fig. 7.20 â&#x20AC;˘ Four-chamber view in transverse approach in a
normal 23-week gestational-age fetus. The size of the color box is intentionally limited to the posterior part of the
left atrium. The low-scale setting highlights the flow in the
left inferior pulmonary vein to guide the position of the sample volume (large white dot) for pulsed Doppler assessment.
DAO descending aorta, LA left atrium, LV left ventricle, PV pulmonary vein, RA right atrium, RV right ventricle, S spine

Fig. 7.21 â&#x20AC;˘ Pulsed Doppler spectrum of the pulmonary vein
of the same fetus as in Fig. 7.20. The velocity of flow of the
systolic (S) and protodiastolic (D) peak is similar. During atrial contraction, (a). the flow stops, and there is a small reversal

CHAPTER 7 • The Four-Chamber View

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71

b

Fig. 7.22 • In a four chamber view, the M-mode cursor (green dashed line) is oriented through the left ventricle, ventricular septum and the right atrium (a). The M-mode trace (b) shows the regular sequence of atrial contractions (arrows)
preceding ventricular contraction (V). LV left ventricle, LVW left ventricular wall, RA right atrium, RAW right atrial wall, VS
ventricular septum

Cardiac Rhythm
Different techniques for assessing cardiac rhythm can
be obtained by M-mode, color flow M-mode, or pulsed
Doppler tracing [29–33]. The basic principle of these
methods is to assess the relationship between atrial and
ventricular contraction. With the M-mode method, the
cursor line should be aligned so that atrial and ventricular wall movement is recorded at the same time.
In the normal sinus rhythm, every atrial contraction
must precede ventricular contraction action and must
be relatively constant and within the normal ranges for
the heart rate. Figure 7.22 shows one example of
M-mode rhythm assessment in the four-chamber view.
If fetal presentation allows the apical four-chamber view to be obtained, the easiest method to evaluate the cardiac rhythm is inflow–outflow pulsed

Doppler assessment of the left ventricle. This method
is described further in the chapter pertaining to the
five-chamber view.

Ventricular Output
As in postnatal examination, transvalvular flow (Q)
can be calculated from the formula:
Q (ml/min) = VTI π D2/4 HR
where D is the diameter of the valve annulus, VTI
is the velocity-time integral of the Doppler flow at
the same site, and HR represents heart rate. In the
four-chamber view, left ventricular output can be calculated from the mitral annulus cross-sectional area
and VTI from the flow through the mitral valve
(Fig. 7.23). The right ventricular output is calculated

72

Echocardiographic Anatomy in the Fetus
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Fig. 7.24 • Apical view in a 22-week gestation-age fetus with
atrioventricular discordance. The left-sided atrium, which receives the pulmonary veins, is connected with a morphologically right ventricle characterized by a moderator band
and a lower insertion of the atrioventricular valve. The rightsided atrium is committed to a morphologically left ventricle
with smooth endocardial surface a higher insertion of the
atrioventricular valve. DAO descending aorta, LA left atrium,
LPV left pulmonary vein, MB moderator band, mLV morphologically left ventricle, MV mitral valve, RA right atrium,
mRV morphologically right ventricle, RPV right pulmonary
vein, S spine, TV tricuspid valve

Fig. 7.25 • Atrioventricular septal defect and atrial component only in a 27-week gestational-age fetus. The yellow arrow indicates a small defect of the atrial septum primum
immediately above the plane of the atrioventricular valves.
The two atrioventricular valves lie on the same plane. Fetal
karyotype revealed a trisomy 21. DAO descending aorta, LA
left atrium, LV left ventricle, RA right atrium, RV right ventricle, S spine

from the tricuspid annulus cross-sectional area and
the VTI from the flow of the tricuspid valve. Despite
the fact that certain assumption of the above formula are not fully satisfied by atrioventricular valves (the
annuli are not circular and the dimension of their orifice is not constant throughout the period of flow),
reliable estimates of ventricular output have been obtained in experimental fetal animal models and in human fetuses [34-36].

tricles of nearly equal size, two equal atrioventricular valves, an apparently intact ventricular septum,
and a left atrium receiving two pulmonary veins.
Knowledge of possible anomalies and systematic adherence to a checklist is therefore mandatory for
successful identification of these abnormalities [37].
The following checklist summarizes the structures
that can be assessed in the four-chamber view:
• position and dimensions of the heart;
• morphology of heart chambers;
• venoatrial connection;
• morphology of the atrial septum and foramen ovale;
• morphology and function of the atrioventricular
valves;
• morphology of the ventricular septum (with exception of the anterior and perimembranous portion);
• ventricular wall thickness;
• dimensions (relative and absolute) of heart chambers;
• ventricular function;
• cardiac rhythm.
It has been proposed also that color flow mapping Doppler, if available, should be used routinely

Four-Chamber-View Checklist
Many examiners may expect that cardiac anomalies
produce severe anatomical distortion in the fourchamber view or a clearly dilated heart. Unfortunately, some heart defects, detectable in the fourchamber view, may present with a nearly normal
four-chamber anatomy, and thus are often overlooked
[37, 38]. Figures 7.24 and 7.25 show two “nearly”
normal four-chamber views in cases with congenital heart disease, which can go undetected by an inexperienced examiner. In both cases, the heart is of
normal size and position, with two atria and two ven-

during screening examination of the heart [38]. Figures 7.17 and 7.19 are associated with a substantial
distortion of the four-chamber view, allowing detection during a routine obstetrical examination, even
without the use of color flow mapping. The utility
of Doppler investigation in such cases is to assess
the severity of valvular dysfunction and follow the
patient in order to optimize perinatal management.

In Figures 7.26 and 7.27, the use of color flow mapping in a first-level obstetrical scan arouses the first
suspicion of a congenital heart disease that may otherwise go undetected.
The four-chamber view in several congenital heart
diseases is shown in the appropriate section on the
DVD-ROM. In the text pertaining to the slides is an
information sheet on that particular disease.

(Figs. 8.2, 8.3). The inflow (through the mitral valve),
outflow, and trabecular component of the left ventricle are displayed, whereas only a portion of the
trabecular part of the right ventricle is seen anteriorly. Posteriorly, the junction of the two upper pulmonary veins with the left atrium and of the superior vena cava with the right atrium are seen.

The Section Plane
With cranial angulation from a four-chamber view,
the left ventricular outflow tract appears wedged between the two atrioventricular valves. With further
cranial angulation, the aortic valve and the aortic root
are imaged (Fig. 8.1).

The Normal Echocardiogram â&#x20AC;&#x201C; 2D

The Normal Morphology

In the normal five-chamber view, only a portion of
the trabecular part of the right ventricle is seen anteriorly. In fact, when the lumen of the aortic root is
visualized, the tricuspid valve and the inlet portion

The fifth chamber in this view refers to the aortic
root, with its valve that is seen in the center of the
heart, with the right and the left atria on its sides

Fig. 8.2 • The five-chamber view is imitated in this specimen, viewed from below. The left ventricular outflow tract
and the aortic valve are seen in the center of the heart.
This figure illustrates how the inflow, the outflow, and the
trabecular part of the left ventricle are included in this
view, whereas only a minor portion of the trabecular part
of the right ventricle is seen anteriorly. Posteriorly, the roof
of both atria is shown. The opening of the superior vena
cava in the right atrium and the junction between the upper left and right pulmonary vein and the left atrium are
visible. The descending aorta, the esophagus, and the right
bronchus are seen in cross section between the posterior wall of the left atrium and the spine. AV aortic valve,
DAO descending aorta, E esophagus, LA left atrium, LPV
left pulmonary vein, LPV left pulmonary vein, LV left ventricle, LVOT left ventricular outflow tract, MV mitral valve,
RA right atrium, RB right bronchus, RPV right pulmonary
vein, RV right ventricle, S spine, SVC superior vena cava

Fig. 8.3 • This specimen of an isolated heart has been cut
to imitate the five-chamber view. This image shows how this
section involves the mitral valve through its anterior (or aortic) (1) and posterior (or mural) (2) leaflet, showing the inflow of the left ventricle from the left atrium. The left ventricular outflow tract is also seen, separated by its inflow only by the anterior leaflet of the mitral valve. The inlet portion
of the right ventricle is not involved in this section, and only the distal portion of the septal (3) and the anterolateral
(4) leaflet of the tricuspid valve is seen. The trabecular portion of both ventricles is displayed. This specimen also shows
continuity between the ventricular septum and the anterior wall of the aortic root and the continuity between the
anterior leaflet of the mitral valve and the posterior wall of
this artery. AAO ascending aorta, AV aortic valve, LA left atrium, LV left ventricle, LVOT left ventricular outflow tract, MV
mitral valve, RA right atrium, RPA right pulmonary artery, RV
right ventricle, TV tricuspid valve

of the right ventricle are not seen because they are
located more caudal to this plane. Anteriorly and to
the left, the left ventricle with its three components
(inlet, trabecular, and outlet) is displayed. More posteriorly, the junction of the two upper pulmonary
veins with the left atrium and the junction of the superior vena cava with right atrium are seen. The descending aorta is displayed between the posterior wall
of the left atrium and the spine (Fig. 8.4a).
In the five-chamber view, the continuity between
the anterior leaflet of the mitral valve and the root
of the aorta is demonstrated. Moreover, this view is

particularly useful to assess the continuity between
the outlet portion of the interventricular septum and
the aortic root anteriorly (Fig. 8.4b). In association
with the long axis view of the left ventricle – which
is more difficult to obtain – this echocardiographic
projection can demonstrate ventricular septal defects
in the subarterial position with or without arterial
overriding [1-4].
In the normal heart, the aortic root has a rightward
takeoff from the long axis of the heart . In the fivechamber view, there is a wide angle between the major axis of the aortic root and that of the ventricular

79

CHAPTER 8 • The Five-Chamber View
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Fig. 8.4 • Cross-sectional five-chamber view in a normal 28-week gestational-age fetus (a). Most structures illustrated
in the anatomical specimen of Figure 8.3 are seen. In a close-up view of the same image (b), the continuity between
the outlet portion of the interventricular septum and the anterior wall of the aorta and the continuity between the
anterior leaflet of the mitral valve and the posterior wall of the aorta are indicated ((yellow arrows). AAO ascending aorta, AV aortic valve, DAO descending aorta, LA left atrium, LPV left pulmonary vein, LV left ventricle, LVOT left ventricular outflow tract, MV mitral valve, RA right atrium, RPV right pulmonary vein, RV right ventricle, S spine, SVC superior
vena cava

septum. In complete transposition of the great arteries, this orientation is missed, and the major axis of
the pulmonary artery, committed to the left ventricle,
is almost parallel to the long axis of the ventricular
septum [5] (Fig. 8.5).

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
With apical presentation, the five-chamber cut is
ideal for Doppler and color Doppler assessment of
the inflow and the outflow of the left ventricle.
This view is useful for assessing the mitral valve,
the left ventricular outflow, and the aortic valve
(Fig. 8.6).
In this view, both diastolic inflow across the mitral valve and systolic outflow toward the aorta may
be sampled by placing the sample volume in between
the ventricular septum and the anterior leaflet of the
mitral valve (Fig. 8.7a). This is a powerful tool for
fetal heart rhythm assessment. For better results, the

sample volume is kept intentionally more ample, between 5 and 10 mm. The atrial rate is indicated by
the frequency of the A waves in the transmitralic inflow spectrum and the ventricular rate by the frequency of the V waves in the outflow spectrum from
the left ventricle [6] (Fig. 8.7b). Two examples of
arrhythmias assessed with this method are shown in
Figure 8.8.
The five-chamber view is ideal for investigating
obstructions to the left ventricular outflow at the
valvular or subvalvular level. Two examples are
shown in Figures 8.9, 8.10.
When a ventricular septal defect is detected in
the subarterial position, this projection is not sufficient to precisely assess the type of ventriculoarterial connection (Figs. 8.11-8.14). In fact, similar images can be obtained in different cardiac malformations as isolated malalignment ventricular septal
defect and tetralogy of Fallot with or without pulmonary atresia [7-9]. Moreover, because of the
oblique orientation of this view, the degree of arterial overriding is best evaluated in the long-axis view
of the left ventricle.

80

Echocardiographic Anatomy in the Fetus

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Fig. 8.5 â&#x20AC;˘ Cross-sectional view and a correlative diagram in a normal heart (a, b) and in transposition of the great arteries (c, d). The black dashed line indicates the long axis of the ventricular septum (and of the heart), whereas the red dashed
line indicates the long axis of the arterial root connected with the left ventricle. In the normal heart, the major axis of the
heart and that of the arterial vessel cross with a wide angle. In transposition of the great arteries, the major axis of the
arterial vessel is nearly parallel to that of the heart. The pulmonary artery is recognized from its early bifurcation. AO ascending aorta, DAO descending aorta, LAA left atrial appendage LV left ventricle, MPA main pulmonary artery, RV right
ventricle, S spine, SVC superior vena cava

CHAPTER 8 â&#x20AC;˘ The Five-Chamber View
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d

Fig. 8.6 â&#x20AC;˘ Cross-sectional and color flow mapping frames in apical presentation in a normal 22-week gestational-age
fetus. The diastolic frames (a, b) show the opening of the mitral valve with filling of the left ventricle (red). There is no
flow into the left ventricular outflow tract, and the aortic valve is closed. In the systolic frames (c, d), the mitral valve
is closed, and the outflow from the left ventricle is seen, filling the root of the aorta (blue). AAO ascending aorta, AV
aortic valve, DAO descending aorta, LV left ventricle, LVOT left ventricular outflow tract, MV mitral valve, RV right ventricle, S spine

82

Echocardiographic Anatomy in the Fetus

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Fig. 8.7 â&#x20AC;˘ Cross-sectional view illustrating the position of the sample volume for Doppler assessment of the inflowoutflow of the left ventricle (a). Doppler tracing (b) shows, above the baseline, the inflow across the mitral valve, with the
A waves (A
( ) corresponding to atrial contractions. V waves (V),
V displayed below the baseline, correspond to the outflow
from the left ventricle because of ventricular contractions. Because the rhythm of A waves is regular and every ventricular contraction is preceded by an atrial contraction, this is interpreted as normal sinus rhythm. AAO ascending aorta,
LA left atrium, LV left ventricle, RV right ventricle, S spine

a

b

Fig. 8.8 â&#x20AC;˘ Inflow-outflow Doppler tracing of the left ventricle for fetal heart rhythm assessment. Bigeminal and blocked
premature atrial contractions (a). The first, third, and fifth beats are anticipated, without early passive ventricular filling
(E),
E and not followed by a ventricular contraction. Two to one atrioventricular block (b). The rhythm of atrial (A
( ) and ventricular (V)
V contractions is regular, but every ventricular contraction is preceded by two regular atrial contractions

CHAPTER 8 â&#x20AC;˘ The Five-Chamber View
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Fig. 8.9 â&#x20AC;˘ A 35-week gestational-age fetus with obstruction of the left ventricular outflow tract due to a single tumor of the interventricular septum (yellow
(
asterisk). This
cross-sectional image (a) shows a circumscribed tumor of
the ventricular septum extending from the midtrabecular portion to the subaortic region. The mass appears homogeneous and slightly more echogenic than the surrounding myocardium. The tumor is protruding to the left,
narrowing the lumen of the left ventricular outflow tract.
Despite the size of the tumor and the reduced size of the
left ventricular outflow tract, the outflow of the left ventricle shows unaliased flow (b). Pulsed Doppler tracing (c)
of the left ventricular outflow in the same patient, with the
sample volume positioned just at the level of the aortic
valve. The Doppler spectrum shows a peak velocity of 79
cm/s, within the normal ranges. AAO ascending aorta, DAO
descending aorta, LV left ventricle, LVOT left ventricular outflow tract, RA right atrium, RV right ventricle, S spine

84

Echocardiographic Anatomy in the Fetus

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Fig. 8.10 â&#x20AC;˘ A 22-week gestational-age fetus with critical aortic stenosis. On cross-sectional view (a), the left chambers are
moderately dilated. On moving images, the left ventricle
shows a poor systolic function. The subvalvar apparatus of
the mitral valve looks thickened and hyperechogenic because of endocardial fibroelastosis. The aortic valve is thickened and with fixed systolic doming. On color flow mapping
(b), two different jets are distinguished: the anterograde flow
through the stenotic aortic valve ((yellow arrow
w) and the jet
of mitral valve regurgitation (white arrow).
w Pulsed Doppler
tracing (c) of the forward flow in the ascending aorta in the
same case. The sample volume was placed in the jet above
the plane of the aortic valve. Despite severe stenosis of this
valve, a relatively low peak gradient (12 mmHg) is present
because of the impaired systolic function of the left ventricle. AOV aortic valve, DAO descending aorta, LA left atrium,
LV left ventricle, MV mitral valve, RV right ventricle, S spine

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Fig. 8.11 â&#x20AC;˘ A 27-week gestational-age fetus with a classic type of tetralogy of Fallot. Subaortic ventricular septal defect (a) indicated by the asterisk;
k the aortic root overrides the crest of the interventricular septum. Posteriorly, the descending aorta is on
the right side of the spine, anticipating a right-sided aortic arch. In the systolic frame with color flow mapping (b), the two yellow arrows indicate ejection of blood from both ventricles into the aorta. Because of the different orientation of the outflows
relative to the ultrasound beam, the flow out from the right ventricle is represented in blue, whereas that from the left ventricle is represented in red. AAO ascending aorta, DAO descending aorta, LA left atrium, LV left ventricle, RV right ventricle, S spine

85

CHAPTER 8 â&#x20AC;˘ The Five-Chamber View
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Fig. 8.12 â&#x20AC;˘ A 31-week gestational-age fetus with tetralogy of Fallot and pulmonary atresia. Tetralogy of Fallot with pulmonary atresia cannot be distinguished from classic tetralogy in this view (a). The cross-sectional picture shows a large
subaortic ventricular septal defect (asterisk)
k with an oversized overriding aorta. The descending aorta is on the right anterior side of the spine due to a right-sided aortic arch. On color flow mapping (b), the ejection of blood into the aortic
root from both ventricles is demonstrated (yellow
(
arrows). Because of the similar orientation of the outflows relative to
the ultrasound beam, the flow is represented in blue in both the right and left ventricles. AAO ascending aorta, DAO descending aorta, LA left atrium, LV left ventricle, RV right ventricle, S spine

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Fig. 8.13 â&#x20AC;˘ A 37-week gestational-age fetus with common arterial trunk. On cross-sectional examination (a), a subarterial ventricular septal defect (asterisk)
k is seen. There is a large arterial root that overrides the defect and appears mostly
committed to the right ventricle. On moving images, the arterial valve looks thickened, with discrete systolic opening.
This diastolic frame on color flow examination (b) shows severe regurgitation of the arterial valve into the right ventricle. AT arterial trunk, ATV arterial trunk valve, LV left ventricle, RV right ventricle, S spine

86

Echocardiographic Anatomy in the Fetus
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Fig. 8.14 â&#x20AC;˘ A 23-week gestational-age fetus with posterior malalignment ventricular septal defect. This defect is associated with interruption of the aortic arch and right aortic arch. On cross-sectional examination (a), both ventricles are
well represented and in normal position. There is a large subarterial ventricular septal defect (asterisk).
k The arterial root
looks small, as does the anulus of its semilunar valve. The descending aorta is on the right side of the spine, anticipating a right aortic arch. Color flow assessment (b) confirms a small anterograde flow through the arterial root and the
sidedness of the descending aorta. AAO ascending aorta, DAO descending aorta, LA left atrium, LV left ventricle, RV right
ventricle, S spine

The three-vessel view is a transverse view of the fetal upper thorax. It can be obtained by sliding the scanning plane cephalad from the four-chamber view toward the fetal upper mediastinum. Obtaining this view
is easy to teach and to learn, as its sonographic plane
is orthogonal to the fetal body long axis. Because most
of the significant lesions involving the ventricular outflow tracts and/or great arteries show an abnormal
three-vessel view, this section is proposed as an alternative to the examination of the ventricular outflow
tracts [1-8]. In Figure 9.1, the level of this section on
the fetal body and on a heart diagram is illustrated.

In the normal heart, the pulmonary trunk is the largest
vessel and most anterior and to the left. The superior
vena cava is the smallest vessel and most posterior and
to the right. The ascending aorta is in between. The
three-vessel view normally shows an oblique section
of the pulmonary trunk and a round cross section of
the ascending aorta and superior vena cava.
The right pulmonary artery arises almost at a right
angle from the main pulmonary artery and runs behind the ascending aorta and superior vena cava to
reach the hilum of the right lung. The left pulmonary
artery arises as an extension of the main pulmonary

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Fig. 9.1 â&#x20AC;˘ The level of the three-vessel view is shown on the fetal body (a) and on a heart diagram (b). Because of the
crossing of the outflows, at the level of this section, the pulmonary artery is to the left of the ascending aorta. AAO ascending aorta, AoV aortic valve, MPA main pulmonary artery, MV mitral valve, PV pulmonary valve, SVC superior vena
cava, TV tricuspid valve

88

Echocardiographic Anatomy in the Fetus
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Fig. 9.2 • This anatomical specimen, viewed from above, is sectioned to imitate the three-vessel plane. Anteriorly and to the
left,
t the oblique section of the main pulmonary artery is seen
giving origin to its right and left branches. The right pulmonary
artery is running behind the ascending aorta and the superior vena cava, which are seen in cross section. The superior
vena cava is the vessel most posterior and to the right, whereas the ascending aorta is in between. In the posterior part of
the mediastinum, the locations of the main stem bronchi, the
esophagus, and the descending aorta are seen. AAO ascending aorta, B bronchus, DAO descending aorta, E esophagus, LPA
left pulmonary artery, MPA main pulmonary artery, RPA right
pulmonary artery, SVC superior vena cava

Fig. 9.3 • Echocardiographic frame of the three-vessel
view in a normal 28-week gestational-age fetus (in caudocranial orientation). All the structures are labeled in the
same fashion as in the anatomical specimen. In the normal fetus, the esophagus is usually difficult to identify
with ultrasound because of its virtual lumen. Here the normal azygos vein in cross section lying in the right paravertebral position is seen. AzV azygos vein, AAO ascending aorta, B bronchus, DAO descending aorta, E
esophagus, LPA left pulmonary artery, MPA main pulmonary artery, RPA right pulmonary artery, S spine, SVC
superior vena cava

artery, lying on a more sagittal plane. In the posterior part of the mediastinum, seen in cross section,
are the two main-stem bronchi, the descending aorta, and the esophagus (Fig. 9.2).

right anterior side of the spine. Due to its virtual lumen in the normal fetus, the esophagus is usually difficult to identify by ultrasound (Fig. 9.3).
Normal ranges for diameters of the three vessels
throughout gestation have been published [6, 8].
However, as a practical rule, to assess the anomalies
of vessel size, the ascending aorta is defined as small
if its diameter is equal to or smaller than the diameter of the superior vena cava or is smaller than the
diameter of the descending aorta in the same image.
The pulmonary artery is considered small if its diameter is equal to or smaller than the diameter of the
ascending aorta. Diagrams in Figure 9.4 illustrate
how spatial alignment, size, and shape of the three
vessels are assessed in this view.

The Normal Echocardiogram – 2D
In this view, the normal echocardiogram shows the
main pulmonary artery, the ascending aorta, and the
superior vena cava aligned along an oblique line and
in decreasing order of their diameter. The main pulmonary artery is the largest vessel, most anterior and
to the left, and the superior vena cava, with the smallest diameter, is the vessel most posterior and to the
right. The ascending aorta is of intermediate size and
is seen in between. To visualize the bifurcation of the
main trunk into its right and left pulmonary arteries,
as in this example, a slight caudal and to the left angulation of the scan plane is usually necessary. The
descending aorta is displayed on the left posterior side
of the spine. With high-resolution ultrasound, the two
main-stem bronchi are frequently seen in the posterior mediastinum and the normal azygos vein on the

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
The usefulness of the three-vessel view is limited in
assessing the flow with color flow mapping. When
this section is truly horizontal, the superior vena ca-

89

CHAPTER 9 â&#x20AC;˘ The Three-Vessel View
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Fig. 9.4 â&#x20AC;˘ Diagrams in caudocranial orientation, illustrating how the spatial alignment (a), the relative size (b), and the different shape (c) of the pulmonary artery, ascending aorta, and superior vena cava can be assessed in this section

va and the ascending aorta are imaged at a right angle and therefore good color signal cannot be
achieved. On the contrary, when this projection is obtained from an anterior approach to the fetal thorax,
the main pulmonary artery is more parallel to the direction of the ultrasound beam, and its flow is easily shown on color flow mapping. With slight probe
manipulation, the flow in the right and left pulmonary
arteries is seen reaching the hilum of the respective
lung (Fig. 9.5). Although Doppler assessment of the
flow in the main pulmonary artery is achieved in this
view, better control of the position of the cursor line
and sample volume is obtained in sagittal or
parasagittal view, as with the long-axis view of the
arterial duct or the right ventricular outflow view,
which will be described in the respective chapters.
Conversely, the three-vessel view is ideal for Doppler
study of the right pulmonary artery. Due to the
anatomical orientation of this branch, parallel alignment of the ultrasound beam is best obtained with
the lateral approach to the fetal thorax.

Three-Vessel-View Abnormalities
According to Yoo and colleagues [1], abnormalities of
the three-vessel view can be classified into four groups:
1. Abnormal vessel size: this occur because of enlarged or reduced size of one or more of the three
vessels (Figs. 9.6-9.8).
2. Abnormal alignment, when the three vessels are
not aligned in a straight line: abnormal vessel
alignment occurs more commonly with subarterial ventricular septal defects of malalignment
type, whether isolated or in the setting of tetral-

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Fig. 9.5 â&#x20AC;˘
tolic frame shows faint color in the ascending aorta and no
color in the superior vena cava due to the unfavorable orientation of these vessels. On the contrary, the flow in the
main pulmonary artery and its branches is clearly represented. AzV azygos vein, AAO ascending aorta, B bronchus,
DAO descending aorta, LPA left pulmonary artery, MPA main
pulmonary artery, RPA right pulmonary artery, S spine, SVC
superior vena cava

ogy of Fallot. Most of these defects are variably
associated with anomalies of the vessel size
(Figs. 9.9, 9.10). A very rare example of aortopulmonary window is shown in Figure 9.11.
3. Abnormal arrangement, when the normal left-toright order of the three vessels is not preserved:
this can occur in complete transposition, congenitally corrected transposition, and malposition

90

Echocardiographic Anatomy in the Fetus

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Fig. 9.6 • A 23-week gestational-age fetus with hypoplastic heart syndrome. The size of the ascending aorta is markedly inferior to that of the pulmonary artery and the superior vena cava. In second-trimester examinations, the vessel is
often so small that it is difficult to identify, even on high-resolution ultrasound. AAO ascending aorta, DAO descending
aorta, MPA main pulmonary artery, S spine, SVC superior vena cava

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Fig. 9.7 • A 31-week gestational-age fetus with coarctation of the aorta. The size of the ascending aorta is relatively small
and similar to that of the superior vena cava. Normal vessel alignment is maintained. AAO ascending aorta, DAO descending
aorta, MPA main pulmonary artery, S spine, SVC superior vena cava

of the great artery, which is most commonly,
although not exclusively, seen in double-outlet
right ventricle (Figs. 9.12–9.14).
4. Abnormal vessel number, when the number of
vessels is increased or decreased: this type of
anomaly includes cases with only two or four vessels. Among the latter, the supernumerary vessel
is more commonly a persistent left superior vena
cava associated with a normal right superior vena

cava. In rare cases, a dilated azygos vein or an
anomalous venous channel can be noted, as in total anomalous venous connection of the supracardiac type. An example of each type is shown
in Figures. 9.15–9.18.
The following figures show some examples of abnormalities of the three-vessel view in the different
groups. Images are displayed in caudocranial presentation.

Fig. 9.9 • A 32-week gestational-age fetus with a “classic” type of tetralogy of Fallot. The size of the pulmonary artery is inferior
to the size of the ascending aorta. The disproportion between the pulmonary artery and the aortic size is a useful means of
predicting the severity of obstruction to the pulmonary flow. Interesting to note, there is also a certain degree of anteriorization of the ascending aorta. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior
vena cava

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Echocardiographic Anatomy in the Fetus

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Fig. 9.10 • A 36-week gestational-age fetus with tetralogy of Fallot with “absent” pulmonary valve. The main pulmonary
artery and its first branches show the characteristic aneurysmatic dilatation. The ascending aorta is also enlarged and
anteriorly displaced. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, RVOT right ventricular outflow tract, S spine, SVC superior vena cava

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Fig. 9.11 • A 32-week gestational-age fetus with an aortopulmonary window. The ascending aorta is moderately dilated
and more anterior and to the right than normal. There is lack of the normal wall separating the ascending aorta from the
main pulmonary artery (asterisk).
k Both the great arteries show increased systolic pulsation on moving images. Associated interruption of the aortic arch cannot be anticipated from this view. AAO ascending aorta, DAO descending aorta, MPA
pulmonary artery, S spine, SVC superior vena cava

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CHAPTER 9 • The Three-Vessel View

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Fig. 9.12 • A 34-week gestational-age fetus with complete transposition of the great arteries (TGA). The ascending aorta is seen anteriorly and to the right relative to the main pulmonary artery. The three vessels appear “crowded” compared
with the normal anatomical arrangement. In complete TGA, some exceptions can be found to the most common location of the great arteries shown in this case. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery,
S spine, SVC superior vena cava

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Fig. 9.13 • A 27-week gestational-age fetus with congenitally corrected transposition. The ascending aorta is the most
anterior and to the left of the three vessels, whereas the main pulmonary artery is between the ascending aorta and
the superior vena cava. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior
vena cava

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Echocardiographic Anatomy in the Fetus
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Fig. 9.14 â&#x20AC;˘ A 23-week gestational-age fetus who had persistent left superior vena cava with absence of the right superior vena cava. The relative size of the three vessels is normal, but their left-right order is distorted. The anomalous superior vena cava is seen to the left of the pulmonary artery. Double-outlet right ventricle is associated, but this anomaly
cannot be anticipated from this view because the great arteries are normally related. AAO ascending aorta, DAO descending
aorta, LSVC left superior vena cava, MPA main pulmonary artery, S spine

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Fig. 9.15 â&#x20AC;˘ Three-vessel view in a 32-week gestational-age fetus with common arterial trunk. Only two vessels are seen:
the large truncal root, which gives origin to the right pulmonary artery, and the superior vena cava. The left pulmonary
artery is not seen because it originates in a more cranial plane. The position of the descending aorta on the right side of
the spine predicts a right-sided aortic arch. AT arterial trunk, DAO descending aorta, RAA right atrial appendage, RPA right
pulmonary artery, S spine, SVC left superior vena cava

95

CHAPTER 9 • The Three-Vessel View

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Fig. 9.16 • A 32-week gestational-age fetus with abnormal vessel number due to the presence of a right superior vena
cava and a persistent left superior vena cava. The supernumerary vessel is seen leftward of the pulmonary artery. The size
of the ascending aorta is abnormally small, similar in size to one of the two vena cava. This fetus had postnatal confirmation of a complex type of coarctation, with tubular hypoplasia of the aortic arch. AAO ascending aorta, DAO descending
aorta, LSVC left superior vena cava, MPA main pulmonary artery, RSVC right superior vena cava, S spine

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Fig. 9.17 • A 35-week gestational-age fetus with total anomalous pulmonary venous connection of supracardiac type.
An anomalous channel is easily identified behind the right pulmonary artery. This channel is a right vertical vein draining the confluence of the pulmonary veins upward into the superior vena cava via the left innominate vein. The superior vena cava is enlarged, draining the anomalous pulmonary venous return. The great arteries are malposed, with the ascending aorta anterior to the left of the pulmonary artery. The size of the pulmonary artery is slightly smaller than the
ascending aorta, anticipating a certain degree of obstruction to the pulmonary flow. AAO ascending aorta, DAO descending
aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, VV vertical vein

96

Echocardiographic Anatomy in the Fetus
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Fig. 9.18 â&#x20AC;˘ A 23-week gestational-age fetus in whom a persistent right umbilical vein drains anomalously into the superior vena cava via the azygos vein. This view shows the azygos vein as a large supernumerary vessel in right paravertebral position. The superior vena cava is severely enlarged because it is receiving (not seen in this view) the flow
of the umbilical vein via the azygos vein. This is a rare case of anomalous drainage of the umbilical vein bypassing the
liver. More commonly, a dilated azygos vein can be seen in cases with inferior vena cava interruption and azygos continuation. AAO ascending aorta, AzV azygos vein, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava

Ascending Aorta and Pulmonary Artery
Disproportion

Relationship of the Great Arteries and
Cardiac Connections

Independently from the type of alignment or arrangement, the disproportion between the size of the aorta and the pulmonary artery in the three-vessel view
anticipates obstruction to the pulmonary or systemic
outflow. Two examples with abnormal arrangement
are shown in Figures 9.19, 9.20.

Normal relationship or malposition of the great arteries can occur in different types of atrioventricular and ventriculoarterial connections as double-outlet right ventricle, tricuspid atresia, or double-inlet
left ventricle. Therefore, a similar pattern of threevessel view can be seen with different types of congenital heart defects. The case in Figure 9.20, and
that shown in Figure 9.22, are two example of this
type. Despite different types of atrioventricular connections, both imitate the three-vessel-view aspect
seen in complete transposition (Fig. 9.12).
In conclusion, the three-vessel view is very useful when anomalies of the ventriculoarterial connection are suspected. However, precise assessment
of the type of connection cannot be predicted from
this view but only through a complete sequential assessment of the heart.

Aortic Arch Sidedness
The position of the descending aorta in the threevessel view anticipates the laterality of the aortic arch.
However the aortic arch sidedness is more easily assessed in the transverse view of the aortic arch. In
Figures 9.15, 9.21b, two examples of right-sided aortic arch are illustrated. All other examples shown in
this section have the aortic arch on the left side.

97

CHAPTER 9 • The Three-Vessel View
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Fig. 9.19 • A 22-week gestational-age fetus with congenitally corrected transposition of the great arteries. The size of the
pulmonary artery is markedly smaller than that of the ascending aorta, anticipating a severe obstruction to pulmonary
flow. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, SVC superior vena cava, S spine

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Fig. 9.20 • A normal case with left aortic arch (a) and a case of tetralogy of Fallot with right aortic arch (b). Tetralogy of
Fallot is associated with right aortic arch in 25% of cases in postnatal series. Microdeletion of the chromosomal region
22q11 has been described more frequently in this setting. AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava

98

Echocardiographic Anatomy in the Fetus
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Fig. 9.21 â&#x20AC;˘ A 30-week gestational-age fetus with tricuspid atresia and discordant ventriculoarterial connection. The great
arteries are malpositioned, with the ascending aorta anterior and to the right relative to the pulmonary artery. The size
of the ascending aorta is small, similar to that of the superior vena cava, predicting obstruction to the systemic flow. This
fetus had postnatal diagnosis of a complex type of aortic coarctation. AAO ascending aorta, DAO descending aorta, LAA
left atrial appendage, MPA main pulmonary artery, S spine, SVC superior vena cava

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Fig. 9.22 â&#x20AC;˘ A 32-week gestational-age fetus with double-outlet right ventricle and malposition of the great arteries. On
cross section, the ascending aorta is located anteriorly and
slightly to the right of the pulmonary artery, thus imitating
a case of complete transposition of the great arteries. A persistent left superior vena cava is seen leftward of the main
pulmonary artery. AAO ascending aorta, DAO descending
aorta, LSVC left superior vena cava, MPA main pulmonary
artery, S spine

ing the descending aorta on the left side of the spine.
The ascending aorta and the superior vena cava appear in cross section on the right side, with their
diameter in decreasing order. With a slight cranial
orientation of the section plane, the upper part of
the right atrial appendage seen anteriorly to these
vessels, whereas the right pulmonary artery, sectioned along its major axis, appears posteriorly. In
the posterior part of the mediastinum, the two mainstem bronchi and the esophagus are displayed in
cross section. When the descending aorta is normally on the left side of the spine, the ductal arch
does not cross the midline and shows a straight
course, leaving these midline structures to its right
side (Fig. 10.2).

The Section Plane
Although some authors include this section into the
category of the three-vessel view [1, 2], here it is described separately. This cut is obtained with a slight
cranial tilt from the classic three-vessel view. The level of this section is shown in Figure 10.1.

The Normal Morphology
In the normal fetus, a transverse section at this level usually should display a transverse section of the
main pulmonary artery and the arterial duct join-

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Fig. 10.1 â&#x20AC;˘ The level of the transverse section of the arterial duct is shown on the fetal body (a) and on a heat diagram (b).
The latter shows that a true transverse cut lies above the level of left and right branch of the main pulmonary artery.
AoV aortic valve, MV mitral valve, PV pulmonary valve, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus
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Fig. 10.2 • An anatomic specimen sectioned to imitate the transverse view
of the ductal arch. This image demonstrates how the arterial duct connects
the main pulmonary artery to the descending aorta. The cross section of the
ascending aorta and the superior vena cava is seen anteriorly, and the two
bronchi and the esophagus are seen
posteriorly. The right pulmonary artery
sectioned along its major axis is displayed between the ascending and the
descending aorta. Anterior to the ascending aorta and the superior vena
cava, the right atrial appendage is involved by this section. AAO ascending
aorta, AD arterial duct, B bronchi, DAO
descending aorta, E esophagus, MPA
main pulmonary artery, RAA right atrial appendage, RPA right pulmonary
artery, SVC superior vena cava

The Normal Echocardiogram – 2D
Echocardiographic sections along a true transverse
plane of the fetal thorax (Figs. 10.3, 10.4) show only the main pulmonary artery joining the descending aorta through the arterial duct. The distal parts
of the infundibulum, the pulmonary valve, and the
right pulmonary artery are not seen because they lie
on a more caudal plane.
True transverse sections of the fetal thorax are more
difficult to obtain because of shadowing of the sternum
and ribs. Consequently, it is easier to obtain a paratransverse section of the thorax from the upper abdomen
with cranial tilt of the probe (Fig. 10.5). With such angulation, the transverse view of the ductal arch includes
the pulmonary valve, the proximal part of the main pulmonary artery, and the right pulmonary branch, this latter being displayed along its major axis (Fig. 10.6).

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
The ductal flow can easily be assessed in transverse
sections with color flow mapping, which shows the
flow from the pulmonary artery toward the descend-

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Fig. 10.3 • Silastic cast of the thoracic aorta and pulmonary
artery in a fetus seen in laterolateral perspective from the
left side. The yellow dashed line indicates the plane of the true
transverse section of the arterial duct. The arch of the arterial duct lies more cranial relatively to the pulmonary valve
and the major branches of the pulmonary artery (dashed circle indicates the origin of the right pulmonary artery). Moreover, the ductal arch lies caudal relatively to the aortic arch.
AD arterial duct, AAO ascending aorta, DAO descending aorta, LPA left pulmonary artery, MPA main pulmonary artery,
PV pulmonary valve, RPA right pulmonary artery

CHAPTER 10 • The Arterial Duct Transverse View

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Fig. 10.4 • Cross-sectional frame (a) and a corresponding diagram (b) of the true transverse view of the arterial duct in
a normal 23-week gestational-age fetus. The main pulmonary artery connects to the descending aorta via the arterial
duct, thus forming the ductal arch. As in the three-vessel view, the ascending aorta and the superior vena cava are seen
in cross section. With high-resolution ultrasound machines, it is common to visualize the distal portion of the azygos vein
arching anteriorly to join the superior vena cava. If the descending aorta is on the left side of the spine, the ductal arch
has a straight course, leaving to its right side the midline structures, the trachea, and the esophagus, which are seen in
cross section in the posterior part of the mediastinum. However, the normal esophagus is usually very difficult to recognize by ultrasound because of its virtual lumen. AAO ascending aorta, AD arterial duct, AzV azygos vein, DAO descending
aorta, E esophagus, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

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Fig. 10.5 • Same image as in Figure 10.3. The yellow dashed
line indicates the plane of the paratransverse section of the
arterial duct with cranial angulation. The plane of this cut
intercepts the proximal part of the main pulmonary artery
and the pulmonary valve. Dashed circle indicates the origin
of the right pulmonary artery. AAO ascending aorta, AD arterial duct, DAO descending aorta, LPA left pulmonary artery,
MPA main pulmonary artery, PV pulmonary valve, RPA right
pulmonary artery

ing aorta via the ductus (Fig. 10.7). This view is sufficient to assess the presence of the normal forward
flow in the arterial duct during routine examination [3].
Doppler assessment of the arterial ductal flow is
easily obtained in transverse sections, demonstrating
the characteristic spectrum of flow from the pulmonary artery toward the descending aorta via the
ductus (Fig. 10.8) [4]. However, sagittal or parasagittal projections are preferable because they allow better control of the precise placement of the sample volume relative to the aortic arch above. Doppler flow
features of the arterial duct are described in the chapter dealing with the arterial duct long-axis view. When
the transverse view of the arterial duct is obtained with
cranial angulation, the distal infundibulum and the
pulmonary valve are seen. Therefore, dysfunction of
this valve can be detected from this view.

The Arterial Duct – Reversed Flow
With severe obstructions of the pulmonary flow, the
flow in the arterial duct is reversed. Usually, in congenital heart disease with pulmonary circulation dependent on the arterial duct, the shape of the ductus
arteriosus is tortuous and more vertical than in the nor-

104

Echocardiographic Anatomy in the Fetus

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Fig. 10.6 â&#x20AC;˘ Cross-sectional view (a) and diagram (b) of a transverse section of the arterial duct in a normal 23-week gestational-age fetus. The section is obtained with the cranial tilt illustrated in Figure 10.5. With such angulation, besides a
section of the main pulmonary artery, the arterial duct, the descending aorta forming the ductal arch, the pulmonary
valve, and the distal infundibulum are seen. The upper part of the right atrial appendage is displayed anteriorly to the
ascending aorta and the superior vena cava, whereas the long-axis section of the right pulmonary artery is seen posteriorly. In the posterior part of the mediastinum and on the right side of the ductal arch, the cross sections of the two
bronchi and the esophagus are displayed. AAO ascending aorta, AD arterial duct, B bronchi, DAO descending aorta, E esophagus, LPA left pulmonary artery, MPA main pulmonary artery, PV pulmonary valve, RAA right atrial appendage, RPA right
pulmonary artery, S spine, SVC superior vena cava

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Fig. 10.7 â&#x20AC;˘ Color flow mapping systolic frames of the transverse view of the arterial duct in true transverse view (a)
and with cranial tilt (b). The normal flow is from the pulmonary artery toward the descending aorta. With ventral
presentation of the fetus, as in these examples, the flow is away from the transducer and is represented in blue.
Good alignment can be obtained for Doppler assessment of both the flow in the main pulmonary artery and the
arterial duct. AAO ascending aorta, AD arterial duct, DAO descending aorta, MPA main pulmonary artery, SVC superior vena cava

CHAPTER 10 • The Arterial Duct Transverse View

105

Fig. 10.8 • Pulse Doppler spectrum of the arterial duct obtained from a transverse view of the arterial duct. The systolic (S) and diastolic (d) peaks of flow are indicated

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Fig. 10.9 • Transverse views of the arterial duct in a 28-week gestational-age fetus with pulmonary atresia and intact
ventricular septum. On cross-sectional examination (a), the relative position, order, and size of the great arteries is maintained. In particular, the size of the main pulmonary artery is larger than the adjacent ascending aorta. There is a wide
arterial duct joining the descending aorta with its full lumen. On color flow mapping (b), the main pulmonary artery is
filled from the arterial duct in a reverse fashion. In fact, despite the ventral presentation of the fetus, the flow direction
in the pulmonary artery is toward the transducer and represented in red. AAO ascending aorta, AD arterial duct, B bronchi,
DAO descending aorta, MPA main pulmonary artery, RPA right pulmonary artery, S spine, SVC superior vena cava

mal fetus. Therefore, it can be difficult to visualize this
vessel in transverse sections. In pulmonary atresia with
intact ventricular septum or severe forms of Ebstein’s
malformation, which are among heart diseases with
duct-dependent pulmonary circulation, the normal
shape of the arterial duct can be maintained, and the
reversed flow is more easily demonstrated [5]. One
example is shown in Figure 10.9.

The Arterial Duct – Short Length
When the pulmonary artery is in the posterior position, the length of the arterial duct is shorter be-

cause this vessel is closer to the descending aorta.
This can be seen in complete or congenitally corrected transposition (Figs. 10.10, 10.11).

The Arterial Duct – Abnormal Shape
On examination during the third trimester, the
arterial duct often shows a certain degree of tortuosity (Fig. 10.12b). In rarer cases, this tortuosity can be particularly pronounced (Figs. 10.13,
10.14). Kinking of the arterial duct is better appreciated in transverse views than in long-axis
views.

106

Echocardiographic Anatomy in the Fetus

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Fig. 10.10 â&#x20AC;˘ Transverse views of the arterial duct in a 36-week gestational-age fetus with transposition of the great arteries. On cross-sectional examination (a), the ascending aorta lies exactly anterior to the pulmonary artery. The pulmonary
artery joins the descending aorta on the posterior side of the spine via a short arterial duct. On color flow mapping (b),
the flow into the arterial duct is normal, from the pulmonary artery toward the descending aorta. AAO ascending aorta,
AD arterial duct, DAO descending aorta, MPA main pulmonary artery, RAA right atrial appendage, RPA right pulmonary
artery, S spine, SVC superior vena cava

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Fig. 10.11 â&#x20AC;˘ Transverse view of the arterial duct in a 27-week gestational-age fetus with congenitally corrected transposition. On cross-sectional view (a), the ascending aorta is located anteriorly and to the left relative to the pulmonary
artery, as is typical in congenitally corrected transposition of the great arteries. Being in the posterior position, the pulmonary artery joins the descending aorta via a short arterial duct. On color flow mapping (b), the normal perfusion of
the arterial duct, from the pulmonary artery toward the descending aorta, rules out a severe obstruction to the pulmonary
flow. AAO ascending aorta, AD arterial duct, DAO descending aorta, MPA main pulmonary artery, RAA right atrial appendage,
RPA right pulmonary artery, S spine, SVC superior vena cava

In rare cases, the arterial duct can reach aneurysmatic size (Fig. 10.15). Most cases of aneurysm of
the arterial duct reported in the literature were incidental findings detected late in gestation [6-9]. The
arterial duct closed spontaneously and did not require
treatment. Some cases associated with complications
have been reported. In transverse sections, the
aneurism can appear as a cystic structure occupying
the upper part of the left thorax [10]. With slight manipulation of the probe, the continuity with the main
pulmonary artery should be demonstrated, with flow
inside the lumen on color flow mapping (Fig. 10.16).

The Arterial Duct – Premature Constriction
or Closure
Because Doppler assessment of arterial duct flow
should be obtained in the long-axis view of the arterial duct, premature ductal constriction or closure
will be discussed in the relative chapter. However,
this type of complication can be suspected also in
the transverse view, and one example is shown in
Figure 10.17.

CHAPTER 10 • The Arterial Duct Transverse View
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Fig. 10.16 • Transverse views of the arterial duct in a 35week gestational-age fetus with aneurism of the arterial
duct. In a true transverse orientation of the fetal thorax (a),
the aneurism of the arterial duct may appear as a cystic
structure in the upper left hemithorax, apparently separated from the lumen of the main pulmonary artery. In a view
obtained with slight parasagittal orientation (b), the continuity between the pulmonary artery and the aneurysmatic ductus is demonstrated. Color flow mapping shows unaliased forward flow through it (c). AAO ascending aorta, AD
arterial duct DAO descending aorta, MPA main pulmonary
artery, S spine, SVC superior vena cava, T trachea

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Fig. 10.17 • Transverse view of the arterial duct in a 29-week gestational-age fetus, with complete closure of the duct.
On cross-sectional view (a), the lumen of the arterial duct is virtually closed. On color flow mapping (b), there is a faint
flow into the main and right pulmonary artery because of the high resistances of the pulmonary circulation. Despite the
unfavorable orientation of the ultrasound beam, the flow in the ascending and descending aortas is well visualized because of redistribution of the cardiac output on the left side of the heart. AAO ascending aorta, AD arterial duct, DAO descending aorta, MPA main pulmonary artery, RPA right pulmonary artery, S spine, SVC superior vena cava

110

Echocardiographic Anatomy in the Fetus

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Fig. 10.18 • Transverse views of the arterial duct in a 23-week gestational-age fetus with aortic arch interruption. On
cross-sectional examination (a), there is a small ascending aorta, similar in size to the superior vena cava. Due to a redistribution of flow to the right side of the heart, the size of the pulmonary artery and the arterial duct is increased. The arterial duct arch crosses the midline, joining the descending aorta on the right side of the spine and leaving the trachea
to the left. These features identify a right-sided arch of the arterial duct and aorta. Color flow mapping (b) confirms a
right-sided arch with increased size of the pulmonary artery and arterial duct. AAO ascending aorta, AD arterial duct, DAO
descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

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Fig. 10.19 • Transverse views of the arterial duct in a 31-week gestational-age fetus with tetralogy of Fallot with pulmonary
atresia. On cross-sectional view (a), the main pulmonary artery is abnormally small, having a size inferior to that of the ascending
aorta. The descending aorta is on the right side of the spine, anticipating a right-sided aortic arch. Although this cross-sectional
view may appear at first sight as a three-vessel view of the pulmonary artery bifurcation, the left branch is represented by an
oblique section of the arterial duct. In fact, the arterial duct, as is common in tetralogy of Fallot and right aortic arch, originated from the foot of the left subclavian artery and was located in the left side of the mediastinum. Color flow mapping (b) shows
a reversed flow into the arterial duct, filling the pulmonary artery retrogradely. AAO ascending aorta, AD arterial duct, B bronchi,
DAO descending aorta, MPA main pulmonary artery, RPA right pulmonary artery, S spine, SVC superior vena cava

The Arterial Duct – Abnormal Position
The arterial duct may show abnormal orientation or
position. For instance, in aortic arch interruption
with right descending aorta, the arterial duct arch

will not be lying on a sagittal plane but on a
parasagittal plane orienting rightward and crossing
the midline (Fig. 10.18). As to abnormal position,
cases with tetralogy of Fallot and right aortic arch
may have the arterial duct originating from the foot
of the left subclavian artery (Fig. 10.19).

tion on the right anterior side of the arch. Posteriorly, the cross section of the trachea at the level of the
carina and of the esophagus is seen. The normal leftsided aortic arch crosses the midline to join the descending aorta in front of the spine and leaves the
trachea and the esophagus on its right side.

The Section Plane
Cranially to the transverse view of the ductal arch,
the transverse view of the aortic arch is obtained. The
level of this section is shown in Figures 11.1, 11.2.
These images illustrate that when the plane of this
section is truly horizontal, the arterial duct and the
pulmonary artery are no longer visible because they
are lying in an inferior plane.

The Normal Echocardiogram â&#x20AC;&#x201C; 2D
In the normal heart, the aortic arch is relatively short
and starts in the middle of the chest, at nearly half of
the anteroposterior diameter between the sternum and
the spine. This is because the aorta is connected with
the posterior left ventricle (Fig. 11.4). The normal leftsided aortic arch shows an oblique course crossing the
midline and merging into the descending aorta in front
of the spine and leaves the trachea and the esophagus

The Normal Morphology
In the normal fetus, this plane shows a transverse section of the aortic arch with an oblique direction from
right anterior to left posterior (Fig. 11.3). The upper
portion of the superior vena cava is seen in cross sec-

Fig. 11.3 â&#x20AC;˘ This normal specimen, viewed from above, is sectioned to imitate the transverse view of the aortic arch. The
aortic arch and the superior vena cava are involved by this section, but the arterial duct and the main pulmonary artery
are not, as they lie in a slightly caudal plane. The normal relationship between the aortic arch and the ascending and the
descending aorta is seen. The trachea, close to its bifurcation (the carina), and the esophagus are seen in the posterior
part of the mediastinum. The dashed line indicates the midline. AAO ascending aorta, AD arterial duct, DAO descending
aorta, E esophagus, MPA main pulmonary artery, SVC superior vena cava

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on its right side. Being filled with amniotic fluid, the
trachea can be visualized sonographically. It can be
differentiated from a vessel because of its bright walls,
due to its cartilaginous rings, and because the lumen
does not code in color on color flow mapping [1, 2].
Due to its virtual lumen, the normal esophagus is difficult to identify on ultrasound examination.

The Thymus

Fig. 11.2 â&#x20AC;˘ Silastic cast of the thoracic aorta and pulmonary
artery seen in laterolateral perspective from the left side. The
yellow dashed line indicates the plane of the transverse section of the aortic arch. The aortic arch lies more cranially to
the arch of the arterial duct. When this section is truly horizontal, the pulmonary artery and the arterial duct are not involved. AAO ascending aorta, AD arterial duct, DAO descending
aorta, LPA left pulmonary artery, MPA main pulmonary artery,
PV pulmonary valve, RPA right pulmonary artery

The anterosuperior part of the mediastinum is mostly
occupied by the thymus, just above the heart and in
front of the three vessels. With high-resolution ultrasound systems, it can be visualized and assessed after
15 weeks of gestation. From the second trimester, it
appears slightly less echoic than the adjacent lungs, and
its parenchyma is visible, containing scattered spindleshaped foci. On close observation, the interface
between the thymus and the lung can be identified
(Fig. 11.5). The normal diameter and perimeter of the
fetal thymus have been published [3, 4]. Agenesia or
hypoplasia of the thymus is a marker for 22q11.2 deletion in conotruncal anomalies (tetralogy of Fallot in all
subtypes, double-outlet right ventricle, common arte-

CHAPTER 11 • The Aortic Arch Transverse View

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Fig. 11.4 • Cross-sectional frame and diagram of the transverse view of the normal aortic arch in a 23-week gestationalage fetus, seen in caudocranial presentation. The aortic arch is relatively short and starts in the middle of the chest. When
the arch is to the left, the trachea lies on its right side. The cross section of the trachea is distinguished from a section
of a vessel by its brighter walls and because its lumen does not code in color on color flow mapping. AAO ascending
aorta, DAO descending aorta, E esophagus, S spine, SVC superior vena cava, T trachea
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Fig. 11.5 • The yellow-shaded area indicates the position of the normal thymus in the anterior part of the mediastinum
in a transverse section of the aortic arch (a) and in a three-vessel view (b). S spine

rial trunk, aortic arch interruption, and ventricular septal
malalignment defects). Prenatal assessment of thymic
hypoplasia or aplasia identifies a group of congenital
heart diseases at high risk for 22q11.2 deletion [5-8].
However, rare false positive and false negative cases
are possible. In a retrospective study of conotruncal
anomalies prenatally detected, 90% sensitivity and
98.5% specificity have been reported [7]. The thymus
can be best assessed in the fetus with a high-frequency probe (8-5 MHz) utilizing a general preset with low
contrast and wide dynamic range.

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
On color flow mapping, in the aortic arch, there should
be nonturbulent forward flow from the ascending aorta toward the descending aorta. The direction of blood
in the aortic arch should be from anterior to posterior,
in the same direction as that in the arch of the arterial duct (Fig. 11.6). Doppler assessment of the aortic
arch can be obtained in transverse view. However, the
sample Doppler can be better positioned in long-axis

views of the aortic arch, which avoids sampling the
flow of the ductal arch below. Therefore, Doppler study
of the aortic arch is discussed in the chapter pertaining to the long-axis view of the aortic arch.

Aortic Arch Abnormal Size
Due to the physiological shortcuts of the fetal circulation, the systemic or pulmonary output can be
redistributed, partially or even totally, into the opposite arterial vessel when severe obstruction to the
pulmonary or aortic outflow is present. The pul-

monary flow can be diverted into the ascending aorta in severe obstruction to the pulmonary circulation. In such cases, the ascending aorta and its arch
are enlarged (Fig. 11.7), whereas the arterial duct is
usually smaller than normal, with inverted curvature
and retrograde perfusion. On the contrary, the aortic flow may be diverted into the pulmonary artery
in severe obstruction to the aortic flow. In such cases, the ascending aorta and its arch is small, with
partial or total retrograde perfusion through the arterial duct and the aortic isthmus (Fig. 11.8). In hypoplastic aortic arches, transverse sections involving the aortic arch only are virtually impossible to

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Fig. 11.7 â&#x20AC;˘ Aortic arch in a 28-week gestational-age fetus with severe pulmonary valve stenosis in the setting of double-outlet right ventricle with normally related great arteries. Due to the significant obstruction to the pulmonary flow, the aortic
arch is enlarged and appears disproportionate to the fetal thorax on cross-sectional examination (a). The arch, to the left, crosses the midline, leaving the trachea on its right. Right and left superior vena cava are seen on both sides of the aortic arch.
Color flow mapping confirms the enlarged aortic arch, which shows increased systolic pulsations on moving images (b).
AAO ascending aorta, DAO descending aorta, LSVC left superior vena cava, RSVC right superior vena cava, S spine, T trachea

117

CHAPTER 11 • The Aortic Arch Transverse View
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Fig. 11.8 • Aortic arch in a 21-week gestational-age fetus with critical aortic valve stenosis in the setting of a hypoplastic left
heart. Although the aortic arch is very small, on cross-sectional examination (a), its left-sidedness is easily appreciated. In
fact, it crosses the midline, leaving the trachea on its right. The upper portion of the dilated pulmonary artery is seen. Color
flow mapping (b) shows a reversed flow into the aortic arch. The flow is from posterior to anterior, approaching the transducer and therefore represented in red. The normal anterograde flow in the main pulmonary artery is represented in blue.
AAO ascending aorta, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

obtain. Usually, these sections also involve the superior portion of the main pulmonary artery and/or
the arterial duct. This is due to dilatation and cranial elongation of the main pulmonary artery and arterial duct because of the redistribution of the aortic output on this artery.

Aortic Arch Interruption
Interruption of the aortic arch can be suspected in
transverse views of the fetal thorax when the normal “oblique sausage” appearance of the transverse
aortic arch cannot be obtained. Cranially to a transverse section of the arterial duct, a cross section of
a very small ascending aorta is obtained (Fig. 11.9),
which usually ends in the two common carotid arteries.

Aortic Arch Sidedness
Provided the examiner includes assessment of the trachea location, the transverse view of the aortic arch
is particularly useful in determining the side of the
aortic arch. Achiron et al. first described the usefulness of the three vessels and trachea view in assessing
the prevalence of aortic arch abnormalities in an un-

selected population [9]. In the last 10 years, a growing number of papers have been published dealing
with this subject [10-16].
In hearts with normally related great arteries, a
right-sided aortic arch lies closer to a sagittal plane
of the body and does not cross the midline. The midline structures, the trachea and the esophagus, are
seen on its left side (Fig. 11.10). In tetralogy of Fallot with aortic arch to the right, the origin of the arterial duct is frequently from the foot of the left subclavian artery. A cross section of the arterial duct is
seen in this view on the left side of the midline (Fig.
11.11). This can be difficult to identify, even for the
experienced examiner.
When the ascending aorta is malposed and in anterior position, the aortic arch is elongated, with a
takeoff behind the sternum (Figs. 11.12-11.14) If the
ascending and descending aortas are on opposite
sides, the aortic arch crosses the midline (Fig. 11.12).
Conversely, when the ascending and descending aortas are on the same side, whether to the left or to the
right, the arch lies in a sagittal plane and does not
cross the midline (Fig. 11.13). However, the most reliable sign to assess the laterality of the aortic arch
is to identify its relative position with the trachea.
This is particularly useful when the aorta is in anterior position and the arch runs in neutral position
close to the midline (Fig. 11.14).

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Echocardiographic Anatomy in the Fetus

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Fig. 11.9 â&#x20AC;˘ Upper mediastinum in a 21-week gestational-age fetus with interruption of the aortic arch. On transverse
view of the arterial duct (a), the ascending aorta is small, similar in size to the superior vena cava. With slight cranial angulation (b), the transverse section of the aortic arch is not obtained, only a cross section of a very small ascending aorta, which is visible ending in the two common carotid arteries on a superior plane (not seen in this image). AAO ascending
aorta, AD arch arterial duct arch, B bronchi, DAO descending aorta, MPA main pulmonary artery, S spine, SVC left superior vena cava, T trachea

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Fig. 11.10 â&#x20AC;˘ Aortic arch in a 22-week gestational-age fetus with a classic type of tetralogy of Fallot (a), and a correlative
diagram (b). The takeoff of the aortic arch is in its normal position in the middle of the thorax, as in aortic arches in normal relationship to the posterior ventricle. The arch is right sided, lying parallel to the midline and leaving the trachea
on its left. AAO ascending aorta, DAO descending aorta, S spine, SVC superior vena cava, T trachea

CHAPTER 11 • The Aortic Arch Transverse View

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Fig. 11.11 • Aortic arch in a 31-week gestational-age fetus
with tetralogy of Fallot and pulmonary atresia (a, c) and a
correlative diagram (b). On cross-sectional view, the takeoff
of the aortic arch is in the normal position in the middle of
the thorax, as in aortic arches in normal relationship to the
posterior ventricle. The arch is right sided, lying parallel to
the midline and leaving the trachea on its left side. The arterial duct originates from the foot of the left innominate
artery (not visible in this image). A cross section of the arterial duct is seen between its origin and the junction with
the pulmonary artery (a). Color flow mapping (c) demonstrates the reversed flow in red ((yellow arrow
w) in the arterial
duct flowing toward the main pulmonary artery (not seen
in this picture). AAO ascending aorta, AD arterial duct, DAO
descending aorta, S spine, SVC superior vena cava, T trachea

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Fig. 11.12 • Aortic arch in a 32-week gestational-age fetus with malposition of the great arteries (a) in the setting of double-outlet right ventricle and correlative diagram (b). The ascending aorta is anterior and to the right. Cross-sectional examination shows an elongated left aortic arch crossing the midline and leaving the trachea on its right side. AAO ascending aorta, DAO descending aorta, S spine, SVC superior vena cava, T trachea

120

Echocardiographic Anatomy in the Fetus

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Fig. 11.13 â&#x20AC;˘ Aortic arch in a 25-week gestational-age fetus with transposition of the great arteries (a) and a correlative
diagram (b). The ascending aorta is anterior to the left, a very rare but possible position in complete transposition of the
great arteries. The aortic arch is longer than normal and does not cross the midline, lying, instead, on a left sagittal plane.
The position of the trachea on the right side confirms the left sidedness of the aortic arch. AAO ascending aorta, DAO descending aorta, S spine, SVC superior vena cava, T trachea

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Fig. 11.14 â&#x20AC;˘ Aortic arch in a 25-week gestational-age fetus with tricuspid atresia and discordant ventriculoarterial connections. Cross-sectional frame (a) and a correlative diagram (b). The ascending aorta is in anterior position. The aortic
arch shows a long takeoff, which starts immediately behind the sternum and runs in neutral position close to the midline. However, the arch is clearly to the left because it leaves the trachea on its right side. The origin of the right innominate artery is also visible. AAO ascending aorta, DAO descending aorta, RIA right innominate artery, S spine, SVC superior vena cava, T trachea

The Arterial Duct and Aortic Arch
Transverse View
the esophagus. In the normal anatomy, there is no vascular structure coursing behind the trachea (Fig. 12.2).

The Section Plane
From the transverse view of the aortic arch, with
slight angulation of the ultrasound beam caudal and
to the left, a simultaneous section of the aortic arch
and arterial duct can be obtained. Figure 12.1 shows
the level of this section.

The Normal Echocardiogram â&#x20AC;&#x201C; 2D
On cross-sectional examination of the normal fetus, this view shows, as a V shape, the confluence
of the ductal and aortic arch, with the descending
aorta at the left anterior corner of the spine. The left
arm of the V is formed by the main pulmonary
artery and the arterial duct, and the right arm is
formed by the aortic arch. In the normal fetus, the
arterial duct arch is slightly larger than the aortic
arch. Both arches are on the left side of the trachea,
which is seen in cross section, filled with amniotic fluid (Fig. 12.3). This view was designated by

The Normal Morphology
The aortic and ductal arches merge together into the
descending aorta, with an acute angle between the
two. The arterial duct is slightly larger than the aortic isthmus. Both arches sit on the left side relative
to the midline structures, which are the trachea and

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Fig. 12.1 â&#x20AC;˘ Level of the transverse view of the arterial duct and the aortic arch. Because the arterial duct lies on a plane that
is inferior and to the left relative to the aortic arch, this section is obtained with leftward and caudal tilt of the scan plane from
the true horizontal view of the aortic arch. AoV aortic valve, MV mitral valve, PV pulmonary valve, TV tricuspid valve

124

Echocardiographic Anatomy in the Fetus

Fig. 12.2 â&#x20AC;˘ This normal anatomical specimen, seen from above, is cut to imitate the transverse view of the ductal and aortic arches. The ductal arch is formed by the confluence of the main pulmonary artery into the descending aorta via the
arterial duct. In the normal heart, the ductal and aortic arches merge together into the descending aorta close to the anterior left side of the spine. The arterial duct is slightly larger than the aortic isthmus. In this fetus, who had an unexpected
spontaneous death at 38 weeks gestation, the arterial duct shows well-formed endothelial folds, which are the anatomical substrate preparing the vessel for postnatal closure. The relationship between the two arches and the bifurcation of
the trachea (carina) and esophagus are demonstrated. No vascular structure is coursing behind the trachea. AAO ascending
aorta, AD arterial duct, DAO descending aorta, E esophagus, Ist isthmus, LAA left atrial appendage, MPA main pulmonary
artery, RAA right atrial appendage, SVC superior vena cava

Yagel et al. [1, 2] as the three-vessel and trachea
view (3VT). In the normal fetus, no vascular structure should be seen behind the trachea, and any
branch coursing behind it should be considered an
aberrant vessel. The diameter of the two arches can
be compared in this view, and significant discrepancies between the two can be detected. However,
due to the oblique nature of this view, absolute assessment of the size of the great arteries is not reliable. Thus, they are better evaluated in views with
the beam at right angle to the structure to be measured. Although measurement of the dimensions of
the great arteries is not necessary during a normal
fetal scan, this should be done whenever a suspicious disproportion is noted. Values should be compared with normal ranges, plotted against gestational age, of large published series [3, 4].

The Normal Echocardiogram â&#x20AC;&#x201C; Color Flow
Mapping
Whether the fetus is in ventral or dorsal presentation, in the normal heart, the aortic and ductal arches show the same direction of blood flow on color
flow mapping examination (Figs. 12.4, 12.5). In dorsoanterior presentation and when the aortic arch is
normally to the left, this view is obtained only with
the left paravertebral approach (Fig. 12.5).
In the normal fetus approaching term, there can
be a brief reversed flow into the isthmus of the aorta in early diastole (Fig. 12.6). This is thought to be
the result of the changing ratio between cerebral and
placental resistance with advancing gestation. This
observation per se does not reinforce suspicion of
systemic outflow obstruction [5].

CHAPTER 12 • The Arterial Duct and Aortic Arch Transverse View

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Fig. 12.3 • Cross-sectional echocardiographic frame and corresponding diagram of the transverse view of the arterial
duct and aortic arches, shown in caudocranial presentation. The V
V-shaped confluence of the two arches in the descending aorta at the left anterior corner of the spine is displayed. Both arches are located to the left of the trachea. AAO ascending aorta, AD arch arterial duct arch, AO arch aortic arch, DAO descending aorta, MPA main pulmonary artery, RAA
right atrial appendage, S spine, SVC superior vena cava, T trachea

With severe pulmonary flow obstruction, as in pulmonary atresia or critical pulmonary stenosis, the pulmonary artery is partially or totally perfused retrogradely through the arterial duct. Usually, the transverse view of the arterial duct is difficult to obtain
together with the aortic arch, because the arterial duct
in these cases is tortuous and lies in a more vertical
plane (Fig. 12.8).

With severe aortic outflow obstruction, as in critical
aortic valve stenosis or atresia, the ascending aorta
and the aortic arch are partially or totally perfused
retrogradely through the arterial duct. Usually, the
aortic arch shows a degree of hypoplasia proportional
to obstruction severity (Fig. 12.7).

CHAPTER 12 • The Arterial Duct and Aortic Arch Transverse View
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Fig. 12.7 • Cross-sectional and color flow mapping transverse view of the arterial duct and aortic arch in a 30-week gestational-age fetus with aortic atresia and hypoplastic left heart. The aortic arch (a) shows a normal takeoff in the middle of
the thorax, but it is very small compared with the ductal arch. The aortic arch is normally left-sided, leaving the trachea on
its right side. The distal part of the azygos vein is seen, describing a sagittal arch, from the right-posterior paravertebral space
to join the superior vena cava anteriorly. On color flow mapping (b), flow direction into the arterial duct arch is normal from
the pulmonary artery toward the descending aorta, and is represented in blue. The small aortic arch is perfused retrogradely
in posteroanterior fashion and is represented in red. AAO ascending aorta, AD arch arterial duct arch, AO arch aortic arch, AzV
azygos vein, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

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Fig. 12.8 • Arterial duct and aortic arch transverse views in a 33-week gestational-age fetus with pulmonary atresia and
intact ventricular septum, with the fetus in dorsoanterior presentation. On cross-sectional scanning (a), this is in reality a
transverse section of the arterial duct because the aortic arch is not seen, being on a more cranial plane. The arterial duct
is small and tortuous, whereas the ascending aorta is enlarged. On color flow mapping (b), the arterial duct is perfused in
retrograde fashion. Although the transverse aortic arch is not seen on 2D images, on color flow mapping, its flow is well
represented because it is sampled by color Doppler on the azimuthal plane. AAO ascending aorta, AD arch arterial duct
arch, AO arch aortic arch, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

128

Echocardiographic Anatomy in the Fetus

Pseudoatresia of the Pulmonary Valve
With severe tricuspid valve regurgitation, as is common in Ebsteinâ&#x20AC;&#x2122;s malformation or tricuspid valve dysplasia, the pulmonary artery can be totally perfused
retrogradely through the arterial duct, even in the absence of organic obstructions to right ventricular outflow. Pseudoatresia of the pulmonary valve can be
the consequence of tricuspid valve regurgitation, with
inability of the right ventricle to generate sufficient
systolic pressure to open the pulmonary valve (Fig.
12.9) [6, 7]. Reversed flow in the arterial duct and
the main pulmonary artery is not sufficient to distinguish between functional and organic atresia of the
pulmonary valve, which can coexist with tricuspid
valve incompetence. Pseudoatresia is suspected
when the pulmonary valve, investigated in other
views, does not show systolic opening but diastolic
regurgitation is present.

Vascular Ring
Aortic arch anomalies include a variety of congenital abnormalities of aortic arch position or branching or both. Some patterns are simple positional
anomalies, but others form a complete or incomplete
vascular ring around the trachea and esophagus. The
ductal and aortic arch transverse view is most useful in diagnosing these cases [8-10]. After right aor-

tic arch with mirror image branching, the second
most common anomaly is a right aortic arch associated with an aberrant left subclavian artery and leftsided arterial duct. On transverse views, the aortic
arch and arterial duct are seen forming a U-shaped
U
vascular loop around the trachea (Fig. 12.10). A coronal longitudinal view of the fetal body, ventrally from
the spine, and the use of power Doppler ultrasound,
hare been proposed as an alternative ultrasound technique for prenatal assessment of this vascular anomaly [11]. Although aberrant left subclavian artery and
left-sided arterial duct realize a vascular ring, the majority of these cases have no symptoms, as the vascular ring is loose.

Azygos Vein Dilatation
The normal azygos vein can be imaged in nearly
50% of normal fetuses in the second trimester and
in 98% of cases in the third trimester [12]. The most
common cause of azygos vein dilatation is interruption of the inferior vena cava with azygos continuation, a condition most commonly seen in left
isomerism of the atrial appendages [13, 14]. More
rarely, the flow into the azygos vein can increase
for different reasons, as in some forms of anomalous
drainage of the pulmonary veins or umbilical vein.
A dilated azygos vein can be seen in this transverse

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Fig. 12.9 â&#x20AC;˘ Arterial duct and aortic arch transverse view in a 37-week gestational-age fetus with Ebsteinâ&#x20AC;&#x2122;s malformation of the
tricuspid valve, with the fetus in dorsoanterior presentation. On cross-sectional examination (a), the pulmonary artery is smaller than the aorta. On moving images, the pulmonary valve cusps show little systolic motion, with incomplete opening. This
was the consequence of significant tricuspid valve regurgitation with negligible forward flow and functional atresia of the
pulmonary valve. Color flow mapping (b) confirms the different sizes of the two great arteries. The arterial duct is retrogradely
perfused and is therefore represented in blue, whereas the normal flow in the aortic arch is represented in red. AAO ascending aorta, AD arch arterial duct arch, AO arch aortic arch, DAO descending aorta, MPA main pulmonary artery, S spine, T trachea

section forming a third arch on the right side of the
trachea, with flow direction opposite that into the
aortic and ductal arches (Fig. 12.11).

The Transverse Views of the Fetal Body:
an Overview
Summary
The diagram in Figure 12.12 summarizes the transverse and paratransverse views discussed so far in

Fig. 12.10 â&#x20AC;˘ Arterial duct and aortic arch transverse views
and a corresponding diagram in a 35-week gestational-age
fetus with a vascular ring. On cross-sectional images (a), the
two arches are split, with a U-shaped appearance and with
the trachea located in between. The aortic arch is to the right
of the trachea, lying in a sagittal plane. The arterial duct arch
is normal, to the left of the midline, but here it joins the descending aorta posteriorly to the trachea, therefore forming a posterior ring around the midline structures. Color flow
mapping (b) confirms the right sidedness of the aortic arch,
with the arterial duct joining the descending aorta in front
of the spine and posteriorly to the trachea. Corresponding
diagram (c). AAO ascending aorta, AD arch arterial duct arch,
AO arch aortic arch, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

this and previous chapters in which the fetal echocardiographic examination is based on short-axis views
of the heart. Long-axis views often represent the most
difficult and time-consuming part of the examination,
which lengthens examination time and often necessitates waiting until the fetus assumes a more favorable presentation. Because transverse views are
more quickly and easily obtained, it has been proposed that the fetal heart be examined on transverse
planes [1]. The examiner can obtained these sections
by sliding the scanning plane in a continuous motion cephalad, from the upper abdomen to the upper
part of the thorax.

130

Echocardiographic Anatomy in the Fetus
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Fig. 12.11 â&#x20AC;˘ Transverse views of the arterial duct and aortic arch in a 23-week gestational-age fetus with absence of the
venous duct with persistent right umbilical vein draining into the superior vena cava via the azygos vein. On cross-sectional examination (a), three arches are seen. The aortic arch is in the middle. It is in the normal left-sided position because it crosses the midline and leaves the trachea on its right side. Due to high cardiac output circulation, it appears
slightly dilated and with increased pulsation on moving images. The arterial duct arch, which in the normal heart joins
the descending aorta in front of the spine, is on the left. The arch on the right side of the midline is formed by an exceptionally dilated azygos vein that arches anteriorly and joins the superior vena cava. On color flow mapping (b), the
flow into the aortic arch and that of the arterial duct show a normal anteroposterior direction, from the ascending aorta and main pulmonary artery toward the descending aorta. It is therefore represented in blue. The flow into the azygos
vein has a posteroanterior direction, from the right paravertebral space toward the front where the vein merges into the
superior vena cava. It is therefore represented in red. Corresponding diagram (c). AAO ascending aorta, AD arch arterial
duct arch, AO arch aortic arch, AzV azygos vein, DAO descending aorta, MPA main pulmonary artery, S spine, SVC superior vena cava, T trachea

Fig. 12.12 â&#x20AC;˘ This diagram summarizes the transverse and paratransverse section of the fetal thorax for heart assessment:
the four-chamber view (1), the most caudal section; the five-chamber view (2), with its cranial angulation relative to the
true transverse plane; the three-vessel view (3), with the bifurcation of the main pulmonary artery; the arterial duct transverse view (4); the aortic arch transverse view (5); the arterial duct and aortic arch transverse view (6), with its left and
caudal angulation

PART II
Echocardiographic Projections
A Transverse Views of the Fetal Body

CHAPTER

13

The Inferior and Superior Vena Cava
Long-Axis View (The Bicaval View)
the right lobe of the liver, where a section of the umbilical vein and the ductus venosus is visible. Inside the
cavity of the right atrium, the terminal crest is shown,
with pectinate muscles branching at a right angle and
running anteriorly into the right atrial appendage. Posteriorly to the terminal crest, the venous part of the right
atrium is displayed, receiving the superior and inferior vena cava. The proximal portion of the inferior vena cava is enlarged because it drains the flow from the
venous duct and the suprahepatic veins and is overridden by the crista dividens, which is the superior portion of the interatrial septum. The upper atrial septum
separates the right from the left atrium and represents
the superior rim of the foramen ovale. The short axis
of the right pulmonary artery is visible behind the superior vena cava, close to its junction with the right atrium. A section of the thymus is seen between the anterior wall of the thorax and the superior vena cava.

The Section Plane
This view is obtained by orienting the scan plane
along the true sagittal plane of the fetal body immediately to the right of the midline (Fig. 13.1). Alternatively, it is easily obtained with slight translation from a long-axis view of the aortic arch obtained from a parasagittal view of the right chest
(Fig. 13.2b). Because this view shows the connection of superior and inferior vena cava with the right
atrium, it is also called the bicaval view.

The Normal Morphology
In the specimen shown in Figure 13.3, the fetal thorax
is cut in a simulated echocardiographic plane in the bicaval view. The right atrium sits on the diaphragm above

Fig. 13.2 â&#x20AC;˘ Normal bicaval view in a 36-week gestational-age fetus (a). Open arrowheads indicate the anterior portion of the
diaphragm. The arrowhead indicates the posterosuperior portion of the interatrial septum, which delimits superiorly the
foramen ovale (yellow
(
arrow
w) and overrides the proximal portion of the inferior vena cava (asterisk).
k A short tract of the descending aorta is seen posteriorly, in front of the spine. The diagram (b) shows the small angle between the plane of the
long-axis view of the aortic arch and that of the bicaval view. From the long-axis view of the aortic arch, the bicaval view is
easily obtained with slight rightward angulation ((yellow arrow
w) of the scanning plane, maintaining the descending aorta as
the center of this rotation. AAO ascending aorta, DAO descending aorta, IVC inferior vena cava, LA left atrium, RAA right atrial appendage, RPA right pulmonary artery, SVC superior vena cava, T trachea, TC terminal crest, Th thymus

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Fig. 13.3 â&#x20AC;˘ Anatomical specimen of the normal fetal thorax sectioned along a parasagittal plane to imitate the long-axis view of the superior and inferior vena cava. The relationship of the two vena cavas with the right atrium and the upper portion of the interatrial septum (arrowhead) is shown. The size of the inferior vena cava increases above the level of
the confluence of the ductus venosus and the suprahepatic veins (asterisk).
k The yellow arrow indicates the foramen ovale,
the natural opening between the two atria. Below the level of the diaphragm (open arrowheads), the terminal part of the
umbilical vein and the ductus venosus is seen. Due to a left oblique angulation of this section, the descending aorta is
displayed in the bottom part of the picture (see text for details). DAO descending aorta, DV ductus venosus, IVC inferior
vena cava, LA left atrium, RAA right atrial appendage, RPA right pulmonary artery, SVC superior vena cava, TC terminal
crest, Th thymus, UV umbilical vein

The Normal Echocardiogram – 2D
On echocardiographic assessment, the bicaval view
shows the superior and inferior vena cava in a longitudinal section, along with their junction with the
right atrium. In the normal fetus, the size of the vena
cavas is similar, with the exception of the proximal
part of the inferior vena cava, which enlarges when
receiving the flow from the umbilical and suprahepatic veins. The right atrial appendage is displayed
anteriorly and a small portion of the left atrium posteriorly, separated by the posterosuperior part of the
atrial septum. The pectinated muscles are not visible on cross-sectional echocardiography. The right
pulmonary artery is imaged in cross section behind
the superior vena cava and above the roof of the left
atrium [1].
With slight manipulation of the transducer, the
distal portion of the umbilical vein, the ductus venosus, and usually one suprahepatic vein is visible inside the liver. The Eustachian valve is seen in the
right atrium close to the mouth of the inferior vena
cava. When this view is obtained from the right chest
and with right-to-left angulation, a portion of the descending aorta is visible posteriorly along the spine
(Figs. 13.2, 13.4).

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
Transducer positions that provide the best representation of the anatomical structures often are not those
that provide the best flow detection on Doppler examination. In fact, anatomic imaging is most effective when the echocardiographic targets are perpendicular to the ultrasound beam, whereas flow detection by Doppler is most effective when targets (red
blood cells) are parallel to the ultrasound beam. The
bicaval view is one of the best examples in which
anatomical study and flow investigations require different approaches with the ultrasound beam.
When the bicaval view is obtained by an approach
to the fetal body at the heart level, the two vena cava
are investigated at a right angle by the ultrasound
beam. Figures 13.2 and 13.4 show how many anatomical details are detected by this approach. On the other hand, with this angulation, the flow inside the two
veins appears relatively faint on color Doppler examination due to the unfavorable interrogation angle.
Black areas can appear inside the color map on the
vessel not only because no Doppler shift is detected
but also because the flow velocity may be inferior to
the minimal threshold. Moving the transducer caudally
or cranially improves flow representation by reducing the interrogation angle. Moreover, keeping the
scale threshold as low as 20 cm/s highlights the lowvelocity flow of the vena cava (Fig. 13.5).

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Fig. 13.4 • This slightly modified bicaval view shows the
Eustachian valve and a section of one suprahepatic vein
below the diaphragm (open arrowheads). Also in this section, a short tract of the descending aorta is seen posteriorly to the left atrium. DAO descending aorta, EV Eustachian valve, HV hepatic vein, IVC inferior vena cava,
LA left atrium, RPA right pulmonary artery, SVC superior
vena cava

Sagittal or parasagittal views of the fetal body
are the best projections to evaluate the flow of the
inferior or superior vena cava. Even in the presence
of a favorable fetal position, it is rarely possible to
align the ultrasound beam with the flow in the vena cava at an angle less than 30°. The flow from
the inferior vena cava in the intrathoracic area is
joined to that of the proximal ductus venosus and
the suprahepatic veins. Animal-model studies have
demonstrated how these flows have different velocities and tend not to mix with one another [2].
The blood from the left suprahepatic vein (which
receives the ductus venosus blood flow) drains into the left dorsal portion of the caval flow and is
oriented toward the foramen ovale by the Eustachian valve and the upper portion of the interatrial septum (crista dividens). Therefore, the left sections of the heart receive a significant portion of the
placental blood flow, with a higher oxygen concentration, which is distributed to the coronary and
cerebral circulation through the ascending aorta.
Blood coming from the abdominal portion of the
inferior vena cava and the other two suprahepatic
veins (middle and right) drain into the right ventral
portion of the caval flow of the superior vena cava
and is oriented in the right cardiac cavity. Due to
this double source of flow in its terminal tract, evaluation of the inferior vena cava should ideally be
done by positioning the sample volume in the abdominal tract between the renal veins and the outlet of the ductus venosus (Fig. 13.6a). However, as

this is no easy technical feat, imaging the flow in
the suprahepatic vein as been proposed as a valid
alternative [3].
The caval flow shows a triphasic profile
(Fig. 13.6b). A systolic anterograde peak (S wave)
is observed due to the atrial “suction” produced
by the movement of the tricuspid valve plane in
an base-to-apex direction during ventricular systole. A lower anterograde peak (D wave) is observed during early diastole, which corresponds to
the reduction in atrial pressure produced by the
opening of the atrioventricular valve and the subsequent passive filling of the ventricle. A small retrograde wave (A wave) is observed in late diastole during atrial contraction. In the normal fetus,
the ratio of the reverse flow during atrial contraction to the forward flow (systolic and diastolic)
decreases as gestation advances. In the third
trimester, this ratio should be 10% or less of the
anterograde flow [4].
As it is difficult to obtain correct alignment of
the ultrasound beam, the absolute velocities of the
vena cava are usually not evaluated. Instead, some
indices, such as the ratio between systolic and diastolic peak velocities, are used. This ratio, which
expresses flow pulsatility, is more or less constant
with a value of 1.8 ± 0.2 throughout the entire gestation period [5-7]. The flow profile of the superior vena cava is similar to that of the inferior vena
cava, although with less inversion during atrial contraction.

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Fig. 13.6 • Sagittal view of the inferior vena cava in a 22-week gestational-age fetus illustrating the position of the sample volume for inferior vena cava Doppler assessment (a). This view is obtained with an approach to the superior part of
the fetal thorax that keeps the angle between the ultrasound beam and the flow into the vena cava as small as possible.
Color flow mapping facilitates the position of the sample volume inside the vessel for pulsed Doppler assessment. Corresponding pulsed Doppler flow profile (b) showing systolic (S) and diastolic (D) waves of the forward flow and reversed
flow (a) during atrial contraction. DAO descending aorta, IVC inferior vena cava, SVC superior vena cava

Fig. 13.7 • An example of long-axis view of the azygos vein in a normal 36-week gestational-age fetus. On cross-sectional
examination (a), the azygos vein is seen coming from the posterior paravertebral space and arching anteriorly above the
right pulmonary artery and bronchus. The vein joins the posterior aspect of the superior vena cava near its junction with
the right atrium. Because of the oblique angulation of this view, the inferior vena cava is not seen, whereas a small portion of the descending aorta is seen along the spine. Color flow mapping (b) shows the flow into the arch of the azygos
vein coded in red. Although the inferior vena cava is not visible, the flow from this vein is well seen coming from the floor
of the right atrium. The runoff into the descending aorta is displayed in blue along the spine. AzV azygos vein, DAO descending aorta, IVC inferior vena cava, LA left atrium, RAA right atrial appendage, RB right bronchus, RPA right pulmonary
artery, SVC superior vena cava

The Azygos Vein
The azygos vein connects the suprarenal portion of
the inferior vena cava with the right superior vena
cava. It can originate from the right lumbar or renal
vein or from the inferior vena cava. After entering
the thorax through the aortic opening of the diaphragm, it runs medial to the thoracic vertebrae and
to the right of the aorta. Along its intrathoracic
course, it receives the lower ten right intercostal
veins. At the level of the fourth thoracic vertebra, it
arches anteriorly to connect the posterior surface of
the superior vena cava. (See Figure 3.8, Chapter 3).
With favorable fetal presentation, the azygos vein
is visible echocardiographically on a modified bicaval view with slight medial orientation. It is seen
arching above the right bronchus and the right pulmonary artery and veins to join the superior vena cava. On color Doppler, the flow in the azygos vein
arch is coded in opposite color to that in the aortic
arch (Fig. 13.7a, b).

Vena Cava Disproportion
In the normal fetus, the two vena cavas have a similar diameter with the exception of the terminal part
of the inferior vena cava. When one vena cava is disproportionately large, increased flow from different

causes is suspected: arteriovenous fistulas; large tumors with increased vascular supply; anomalous systemic or pulmonary venous drainage [8, 9]. The disproportion between the two veins must be confirmed
by color Doppler assessment. Some examples are
shown in Figures 13.8-13.10.

Azygos Vein Dilatation
The most common cause of azygos vein dilatation
is the interruption of the inferior vena cava with azygos continuation. This is one of the most consistent
features in left isomerism, observed in 78% of cases in postnatal series [10]. A dilated azygos vein can
occur also when this vein is an alternative route to
the heart, for example, because of kinking of the inferior vena cava due to liver herniation in large omphalocele. An interrupted inferior vena cava is often
associated with direct hepatic vein drainage into the
atrial floor. More rarely, the azygos vein can dilate
when it is part of an anomalous drainage of the pulmonary veins or the umbilical vein (Fig. 13.11).
A dilated azygos vein is first suspected by the detection of two vessels nearly equal in size – the aorta and the azygos vein – lying behind the heart on
transverse or long-axis views of the fetal thorax. The
vessel more posterior and to the right is the azygos
vein (Fig. 13.12) [11].

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Echocardiographic Anatomy in the Fetus
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Fig. 13.8 • Bicaval view, with dorsoanterior presentation, in
a 33-week gestational-age fetus with a large intracranial arteriovenous malformation. On cross-sectional image (a), the
superior vena cava is enlarged and tortuous, being the efferent vessel of a large intracranial arteriovenous fistula. Despite the more unfavorable insonation angle, only the flow
of the superior vena cava is well represented because of the
large flow in this vessel coming from the arteriovenous malformation (b). Transverse section (c) of the fetal head showing a large arteriovenous malformation. On color Doppler,
there are multiple vessels connecting with an ovoid
“aneurism” located in the posterosuperior part of the fetal
brain. IVC inferior vena cava, RA right atrium, SVC superior
vena cava

c

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a
Fig. 13.9 •
with a single umbilical artery and two umbilical veins bypassing the liver and joining the iliac vessel. Multiple arteriovenous fistulas of the placenta are associated. On crosssectional imaging (a), a very large inferior vena cava is visible. Because of the considerable venous return from the
placenta draining directly into iliac veins, the size of the inferior vena cava is uniformly large, even well before its terminal portion. Diagram (b) of the umbilical vessels of the
case in a. The ductus venosus is absent and the hepatic veins
are draining into the terminal part of the inferior vena cava. There is a single left umbilical artery and two umbilical
veins draining into the iliac veins. AAO ascending aorta, AO
aorta, HV hepatic veins, IVC inferior vena cava, LUA left umbilical artery, LUV,
V left umbilical vein, PV portal vein, RA right
atrium, RUV right umbilical vein, SVC superior vena cava

Fig. 13.10 • Bicaval view in a 35-week gestational-age fetus with total anomalous drainage of the pulmonary veins to
the right superior vena cava. On cross-sectional image (a), the superior vena cava, and its cranial portion in particular, appears disproportionately large. Color flow mapping (b) confirms the unusual size of the first tract of the superior vena
cava. Due to a more cranial approach on the fetal chest, the flow inside the first portion of the superior vena cava is represented in blue. IVC inferior vena cava, RA right atrium, RV right ventricle, SVC superior vena cava, TV tricuspid valve

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Fig. 13.11 • Long-axis view of the azygos vein in a 21-week gestational-age fetus with dorsoanterior presentation. The
ductus venosus is absent, and a persistent right umbilical vein drained into the superior vena cava via a lower intercostal
vein and the azygos vein. On cross-sectional examination (a), a very large azygos vein is seen joining the superior vena
cava, whose terminal portion is consequently enlarged. Color flow mapping (b) confirms the large flow from the azygos
vein. A small flow from a suprahepatic vein is visible entering the right atrium. AzV azygos vein, IVC inferior vena cava, RA
right atrium, SVC superior vena cava

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Echocardiographic Anatomy in the Fetus
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Fig. 13.12 â&#x20AC;˘ Long-axis view of the fetal thorax, with dorsoanterior presentation, in a 31-week gestational-age fetus who
had interruption of the inferior vena cava and azygos continuation. On cross-sectional scanning (a), two vessels nearly
equal in size are visible in the posterior mediastinum behind the heart. On color flow mapping (b), the two vessel are
filled in red and blue because of the opposite flow direction. On still frame, it is not possible to identify which vessel is
which. On the moving images, the more anterior vessel reveals a pulsatile flow, characteristic of the aorta. The azygos
vein, posteriorly, shows a typical subcontinuous and low-velocity venous flow. AzV azygos vein, DAO descending aorta

superior aspect in the following order: the innominate artery, the left common carotid artery, and the
left subclavian artery. Posteriorly to the arch, the
cross section of the right pulmonary artery and the
right bronchus are seen. Anterosuperiorly, just in front
of the origin of the innominate artery, the innominate vein is displayed in cross section. This vein is
the largest vessel of the upper mediastinum and is
anteriorly embraced by the thymus.
The sagittal view of the aortic arch is a short-axis
view of the heart at the level of the two atria or at the
atrioventricular junction. Usually, a larger portion of
the right atrium with its appendage is seen anteriorly
and a smaller portion of the left atrium posteriorly. This
view displays the superior portion of the interatrial septum (crista dividens) that forms the roof of the foramen ovale. Inferiorly, the junction between the inferior vena cava and the right atrium is visible (Fig. 14.2).

The Section Plane
This view is obtained by cutting the fetal body in a
parasagittal plane with transducer angulation from the
right of the sternum to the left shoulder. As to the
heart chambers, the diagram shows how this view
includes inferiorly an oblique section of the two atria
together with the long-axis view of the aortic arch
(Fig. 14.1).

The Normal Morphology
In the normal heart, the aortic arch long-axis view
shows the ascending aorta arising in the center of the
chest and forming the aortic arch, characterized by
the three head and neck vessels originating from its

Fig. 14.2 â&#x20AC;˘ This section is obtained with a parasagittal cut of the fetal thorax to imitate the long-axis view of the aortic
arch. The aortic arch is seen arising with a narrow curvature between the two atria in the center of the chest. Due to difficulties in obtaining this section in the whole fetal body, only the origin of the innominate artery is seen among the neck
vessels. In the anterosuperior part of the mediastinum, the thymus embraces the innominate vein displayed in cross section. The oblique section of the trachea and esophagus in the neck region are indicated. Behind the arch, the right pulmonary artery and the right bronchus are displayed. The white asterisk indicates the upper portion of the interatrial septum, which superiorly delimits the foramen ovale (white bracket)
t and overrides the opening of the inferior vena cava below. The open arrowheads indicate the diaphragm, with the right lobe of the liver below. AAO ascending aorta, DAO descending
aorta, E esophagus, InA innominate artery, InV innominate vein, IVC inferior vena cava, LA left atrium, RA right atrium,
RB right bronchus, RPA right pulmonary artery, Th thymus, T trachea, UV umbilical vein

The thoracic aorta can be distinguished in its different segments: the ascending aorta, the proximal
arch, the distal arch, the isthmus, and the descending
aorta. These segments are illustrated in Figure 14.3.
The isthmus is the aortic segment between the left
subclavian artery and the aortic end of the arterial
duct. In the normal newborn, the aortic arch shows
progressive tapering of its diameter, with the smallest diameter at the isthmus, which can be up to 60%
smaller than that of the ascending aorta. The progressive reduction of the aortic arch diameter is believed to reflect the proportion of the cardiac output
transversing each segment in the fetal life, with the
smallest amount crossing the isthmus because most
of the blood ejected in the ascending aorta is taken
by the cerebral circulation. In the fetal lamb, only 10%
of the combined ventricular output passes through the

isthmus, compared with 32% of the ascending aorta
and 57% of the arterial duct [1]. Doppler flow studies have demonstrated in the human fetus that the flow
at the isthmus decreases as gestation progresses, and
an early reverse flow can be observed in diastole, particularly near term [2, 3].
The aortic isthmus is a crucial vascular structure
in the fetal circulation, situated between the circulation of the upper part and that of the inferior part
of the body. Circulation of the upper part is characterized by the left ventricle as pumping chamber
and the major peripheral resistance produced by
cerebral circulation. The circulation of the inferior
part is supported by the right ventricle as pumping
chamber and the major peripheral resistance given
by placental circulation (Fig. 14.4). The aortic isthmus may show flow abnormalities not only in case

CHAPTER 14 • The Aortic Arch Long-Axis View

a

145

b

Fig. 14.3 • This anatomical specimen (a) shows the three head and neck arteries originating from the aorta. The aortic
arch is continuous with the descending aorta and receives the arterial duct beyond the isthmus, the segment included
between the origin of the left subclavian artery and the duct itself. The diagram (b) shows the different thoracic aorta
segments (a-d) and their diameters. At the isthmus, the aorta reaches its smallest size. AAO ascending aorta, AD arterial
duct, DAO descending aorta, InA innominate artery, LAA left atrial appendage, LCA left carotid artery, LSA left subclavian
artery, MPA main pulmonary artery, RAA right atrial appendage, SVC superior vena cava

of major ventricular dysfunction and/or obstruction
but also due to imbalance between cerebral and placental resistance.

The Normal Echocardiogram – 2D
Because in the normal heart the aorta arises from the
posterior ventricle, the aortic arch shows on cross-sectional examination as a narrow curvature that has been
suggested as having a “candy-cane” or a “walkingcane” appearance. However, a narrow curvature is not
a sufficient feature to characterize the aorta. In hearts
with malposition of the great arteries and the aorta
in anterior position, the aortic arch curvature is wider.
Therefore, the most specific feature of the aortic arch
is the origin of the three head and neck vessels from
the superior part of this arch. Even with the best presentation of the fetus, it is difficult to visualize all three
vessels at the same time. More frequently, they will
be imaged in a sequential manner with slight manipulation of the scan plane. During this examination,
the integrity of the aortic arch has to be assessed. Being a section along the major axis of the fetal body,
this view shows posteriorly an oblique section of the
spine with several vertebral bodies (Fig. 14.5a).
The long-axis view of the aortic arch can be obtained from a bicaval view with slight leftward tilt

Fig. 14.4 • Circulation in the upper part of the fetal body
is mostly supported by the left ventricle pumping against
vascular resistance of the cerebral circulation. The inferior part of the body is mostly supported by the right ventricle pumping blood against vascular resistance of the placental circulation. The isthmus can receive blood flow from
the two sources depending on the circulatory needs

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Echocardiographic Anatomy in the Fetus

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Fig. 14.5 • Long-axis view of the aortic arch in a normal 28-week gestational-age fetus (a). The “candy-cane” appearance
of the arch is shown. All structures described in Fig. 14.2 are visible. The upper part of the interatrial septum (asterisk) is
seen, representing the superior rim of the oval fossa (bracket). The open arrowheads indicate the outline of the diaphragm.
The diagram (b), depicting the transverse view of the arterial duct, illustrates where the probe must be placed and how
the beam axis is to be oriented to obtain the long-axis view of the aortic arch by 90° rotation of the scan plane. A right
parasternal approach on the fetal thorax is needed. AAO ascending aorta, DAO descending aorta, InA innominate artery,
InV innominate vein, IVC inferior vena cava, LA left atrium, RA right atrium, RB right bronchus, RPA right pulmonary artery,
Th thymus, T trachea

of the scan plane. An alternative method is to start
from a transverse view of the thorax. By placing
the probe on the right side of the sternum and aligning the ascending and the descending aorta on the
ultrasound beam, the long-axis view is obtained after 90° rotation of the scan plane (Fig. 14.5b).
The long-axis view of the aortic arch can be obtained even when the fetus is in dorsoanterior presentation, particularly in the mid trimester when ossification of the rib cage is less pronounced. In the
normal fetus with a left-sided aortic arch, this cut
can be obtained only with a left paravertebral approach. The scanning plane should have a
parasagittal orientation from left posterior to right
anterior. The scanning technique is further discussed in the following chapter. Due to substantial
absorption of the ultrasound energy by the vertebral bodies, scapulae, and ribs, the morphologic details with this orientation are poorer than those obtained with a ventral approach. Nevertheless,
many details can be still recognized. An example
of this view with the paravertebral approach is
shown in Figure 14.6.

The long-axis view of the aortic arch is useful to
assess the shape of the entire arch, to measure the
size of its segments, and for Doppler assessment from
the aortic valve to the descending aorta.

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
Because the flow in the normal aortic arch changes
direction up to 180°, on color flow mapping, different segments of the aorta are represented in opposite colors. Color flow should be laminar in all segments and, with the appropriate setting, a small filling should be seen at the origin of the three head and
neck vessels (Fig. 14.7).
Doppler flow study of the proximal and distal aortic arch is ideally performed by this view. The
Doppler spectrum is characterized by a monophasic
wave, similar to that of the aortic valve, but with a
diastolic forward flow (Fig. 14.8) [4]. This is due to
diastolic recoil of the aortic walls and the low placental resistance.

147

CHAPTER 14 • The Aortic Arch Long-Axis View

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Fig. 14.6 • Long-axis view of the aortic arch in a normal 23-week gestational-age fetus with dorsoanterior presentation
(a). Despite the inferior resolution to that of ventral presentation, several anatomical details are recognizable. The upper
part of the interatrial septum (white asterisk) is seen, delimiting superiorly the oval fossa (white bracket). The diagram (b),
depicting the transverse view of the fetal thorax with dorsoanterior presentation, illustrates where the probe must be
placed and how the beam axis is to be oriented to obtain the long-axis view of the aortic arch by 90° rotation of the scan
plane. A left paravertebral approach on the fetal thorax is necessary. AAO ascending aorta, B bronchus, DAO descending
aorta, InA innominate artery, LA left atrium, LCA left carotid artery, LSA left subclavian artery, RA right atrium, RPA right pulmonary artery

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Fig. 14.7 • Color flow mapping systolic frames of the long-axis view of the aortic arch in two normal 23-week gestationalage fetuses with spine-posterior (a) and spine-anterior (b) presentation. The ascending and descending aortas are visible in opposite colors, with laminar flow in the transverse arch and small filling at the origin of some of the neck vessels.
AAO ascending aorta, DAO descending aorta, InA innominate artery, InV innominate vein, IVC inferior vena cava, LCCA left
common carotid artery, LSA left subclavian artery

148

Echocardiographic Anatomy in the Fetus

b

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Fig. 14.8 â&#x20AC;˘ Pulsed Doppler tracing (a) showing the flow pattern in the distal aortic arch in a normal 20-week gestational-age
fetus. The image being obtained in the paravertebral approach to the fetal thorax, the flow is seen approaching the probe and
therefore is represented above the baseline. Yellow open arrows indicate diastolic runoff from the aorta. The sample volume is
placed in the distal aortic arch with the fetus in dorsoanterior presentation (b). AAO ascending aorta, DAO descending aorta
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Fig. 14.9 â&#x20AC;˘ Long-axis view of the aortic arch in a 33-week gestational-age fetus with hypoplastic left heart. On cross-sectional examination (a), the ascending aorta and the proximal aortic arch are markedly hypoplastic. The narrow curvature
of the aortic arch is maintained, and the origin of the head and neck vessel from its superior margin is demonstrated.
The size of the descending aorta is normal. On color flow mapping (b), the aortic arch is perfused retrogradely by the arterial duct (not seen in this view). AAO ascending aorta, DAO descending aorta, InA innominate artery, InV innominate
vein, LA left atrium, RV right ventricle

The Aortic Arch Abnormalities
In the following sections of common abnormalities
of the aortic arch are shown in this echocardiographic
projection.

Severe Aortic Outflow Obstructions
With severe obstruction to the aortic outflow, the size
of the proximal aorta is generally reduced. Partial or
complete retrograde perfusion through the arterial
duct is seen (Fig. 14.9, 14.10).

Coarctation of the aorta is a common congenital heart disease, accounting for nearly 7% of congenital heart disease in postnatal series. Despite
the published information, coarctation of the
aorta remains a challenging lesion to detect in
utero [5]. Even with optimal technique, coarctation of the aorta is one of the most frequent false
positive and false negative diagnoses in prenatal
cardiac assessment. The incidence of false negative cases is higher in simple lesions and lower in
complex cases. Prenatal diagnosis of coarctation
of the aorta relies on direct and/or indirect echographic signs. Direct signs include visualization

CHAPTER 14 • The Aortic Arch Long-Axis View

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Fig. 14.10 • Long-axis view of the aorta in a 24-week gestational-age fetus with critical aortic valve stenosis. This systolic frame shows a tiny jet of flow passing through the aortic valve into the aortic root. This jet can be easily missed
with low-resolution ultrasound machines or inappropriate
settings. Due to the insufficient anterograde flow, there is
retrograde perfusion of the distal and proximal aortic arch
through the arterial duct (not visible in this view). AAO ascending aorta, DAO descending aorta, InA innominate
artery, InV innominate vein, LA left atrium, RA right atrium,
RPA right pulmonary artery

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Fig. 14.11 • Long-axis view of the aortic arch in a 33-week gestational-age fetus with complex aortic coarctation. The
arch is seen from the posterior approach to the fetal thorax. The cross-sectional image (a) shows a tubular hypoplasia of
the aortic arch, which is particularly narrow at its distal segment. The origins of the head and neck vessels are widely
spaced. Below the confluence of the arterial duct (not visible in this view), the size of the descending aorta is normal. On
color flow mapping (b), there is anterograde unaliased flow in the ascending aorta and a retrograde perfusion (blue) of
the distal aortic arch. AAO ascending aorta, DAO descending aorta, InA innominate artery, LCA left carotid artery, LSA left
subclavian artery, RA right atrium, RPA right pulmonary artery

of a contraductal shelf of the aorta or hypoplasia
of the aortic arch and isthmus (Fig. 14.11) [5, 6].
Although they are the most specific, imaging of
these signs during a routine obstetric examination
is often not practical. Initial suspicion must therefore rely on indirect signs, which include dominant size of the right ventricle and pulmonary
artery over the size of the left ventricle and the
ascending aorta [7-9].
When the aortic arch is interrupted, the continuity between segments of the aortic arch cannot be
demonstrated (Fig. 14.12) [10].

Severe Pulmonary Outflow Obstructions
In contrast to normal fetuses in which the ascending
and the descending thoracic aorta are relatively similar in size, in most lesions with ductal-dependent pulmonary circulation, the ascending aorta is disproportionately large. This is because both ventricles
eject into the aorta or the pulmonary flow is redistributed to the systemic ventricle at the atrial level
through the foramen ovale. Pulmonary flow is provided by retrograde perfusion of the arterial duct or
through collateral arteries (Fig. 14.13).

150

Echocardiographic Anatomy in the Fetus

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Fig. 14.12 â&#x20AC;˘ Aortic arch long-axis view in a 30-week gestational-age fetus with interruption of the aortic arch. The interruption was between the left common carotid artery and the left subclavian artery (type B). A ventricular septal defect
with posterior malalignment of the infundibular septum was associated. There was a left-sided aortic arch. Postnatal fluorescence in situ hybridization investigation revealed a chromosome 22q11 deletion. On cross-sectional examination (a),
the ascending aorta is mildly hypoplastic and shows a straight course ending in the left carotid artery. No continuity of
the aortic arch with the descending aorta is demonstrated. The main pulmonary artery is in continuity with the descending
aorta through the arterial duct. On color flow mapping (b), both great arteries show unaliased flow. Discontinuity between the proximal aortic arch and the descending aorta is confirmed. AAO ascending aorta, AD arterial duct, DAO descending aorta, InA innominate artery, InV innominate vein, LA left atrium, LCA left carotid artery, MPA main pulmonary
artery, RA right atrium, T trachea

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Fig. 14.13 â&#x20AC;˘ Long-axis view of the aortic arch in a 27-week gestational-age fetus with tetralogy of Fallot. A right aortic
arch is associated. On cross-sectional examination (a), the ascending aorta and the proximal arch are disproportionately large. Behind the ascending aorta, two vessels are displayed in cross section. The inferior vessel is a relatively small right
pulmonary artery, and the superior vessel is an innominate vein with a retroaortic course. The aortic arch is right sided,
but laterality of the aortic arch is not appreciated in sagittal views of the fetal body. A retroaortic innominate vein was
seen in three cases in our series, all with tetralogy of Fallot and right aortic arch. Color flow mapping (b) confirms the
large size of the aortic arch, with increased systolic pulsation on the moving images. Due to low-velocity flow, the innominate vein is not coded in color, whereas a turbulent flow, due to pulmonary valve stenosis, fills the right pulmonary
artery. AAO ascending aorta, DAO descending aorta, InV innominate vein, IVC inferior vena cava, LA left atrium, LSA left
subclavian artery, RPA right pulmonary artery, RA right atrium

151

CHAPTER 14 • The Aortic Arch Long-Axis View

Variability of the Plane of the Aortic Arch LongAxis View
Left- or right-sided aortic arch can occur in normal
and abnormal hearts. Moreover, malposition of the
great arteries can occur in different types of abnormal connections such as complete transposition,
double-outlet right ventricle, tricuspid atresia, or
double-inlet right ventricle. The plane of this view
shows wide variability, from a true sagittal plane
to a parasagittal plane with right or left angulation.
This depends not only on the position of the ascending aorta but also on that of the descending aorta. The orientation of the scan plane can be defined
precisely with a transverse view of the thorax and
by aligning the ascending and the descending aorta on the ultrasound beam axis before rotating the
scan plane 90°. Some schematic examples are
shown in Figure 14.14. Echocardiographic examples of the different orientations of the aortic arch
plane are provided in the chapter describing the
transverse view of the aortic arch.

When the aorta is anteriorly positioned, the aortic arch curvature widens, losing its normal narrow
curvature. Consequently, the aorta must be recognized not from the width of its curvature per se but
from the origin of the neck vessels, which is its
more constant feature. The neck vessels can be imaged only in the long-axis view of the aortic arch
(Figs. 14.15, 14.16).

The Aortic Arch in Mitral Valve Atresia with
Ventricular Septal Defect
When mitral valve atresia and concordant ventriculoarterial connection is associated with a ventricular
septal defect, the size of the ascending aorta and aortic arch depends on the dimensions of the defect of
the ventricular septum. If this defect is wide, the size
of the ascending aorta and its arch is usually normal
despite the rudimentary dimensions of the left ventricle. Figure 14.17 shows an example of this type
of defect.

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Fig. 14.14 • Diagrams imitating a transverse view of the aortic arch show the
different orientation of the beam axis
necessary to obtain the long-axis view
of the aortic arch with 90° rotation of
the scan plane. Left-sided (a) and a
right-sided (b) aortic arch with normal
posterior aorta. Left (c) or right (d) arch
when the ascending aorta is anterior
and to the left. The long-axis view of the
aortic arch is obtained with a sagittal
orientation of the scan plane in (b) and
(c), whereas while a parasagittal cut is
necessary in (a) and (d) with an approach from the right and left side
of the sternum, respectively. AAO ascending aorta, DAO descending aorta,
SVC superior vena cava, T trachea

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Echocardiographic Anatomy in the Fetus
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Fig. 14.15 â&#x20AC;˘ Long-axis view of the aortic arch in a 35-week gestational-age fetus with double-outlet right ventricle and
malposition of the great arteries. The aorta is anterior and to the left relative to the pulmonary artery. On cross-sectional examination (a), the aorta, recognized by the origin of the head vessels, shows a curvature wider than normal because
this artery is committed to the anterior right ventricle. The aortic arch is regular in all its segments. Color flow mapping
(b) confirms that this anterior vessel is the aorta, with color filling the origin of the head and neck vessels. The artery
shows normal perfusion by unaliased flow. AAO ascending aorta, DAO descending aorta, InV innominate vein, LSA left
subclavian artery, LCA left carotid artery, LPA left pulmonary artery

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Fig. 14.16 â&#x20AC;˘ Long-axis view of the aortic arch in a 25-week gestational-age fetus with tricuspid atresia and ventriculoarterial discordance. The ascending aorta is anterior and to the right of the pulmonary artery. On cross-sectional examination (a), the most anterior arterial vessel is the aorta because it gives origin to the head and neck vessels. This is despite
the wide curvature of its arch and its connection with the infundibulum behind the sternum. The aorta is far larger than
the main pulmonary artery and runs parallel behind. The infundibular septum is posteriorly deviated and contributes to
the obstruction of the pulmonary flow. This view sections the heart on the atrioventricular junction where a single atrioventricular valve is seen with a two-leaflet morphology on moving images. Color flow mapping (b) confirms the small
size of the pulmonary artery, filled with turbulent anterograde flow, originating at the subarterial conus. Due to the significant obstruction to the pulmonary flow, the small arterial duct shows diastolic inversion of its flow. AAO ascending
aorta, AD arterial duct, AoV aortic valve, DAO descending aorta, InA innominate artery, IS infundibular septum, LPA left pulmonary artery, MPA main pulmonary artery, MV mitral valve, RAA right atrial appendage, T trachea

153

CHAPTER 14 â&#x20AC;˘ The Aortic Arch Long-Axis View
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Fig. 14.17 â&#x20AC;˘ Long-axis view of the aortic arch in a 23-week gestational-age fetus with atresia of the mitral valve associated with ventricular septal defect. On cross-sectional examination (a), all aortic segments are mildly hypoplastic, with
a normal curvature of the arch. The origin of the head and neck vessels is demonstrated. The foraminal flap, bulging
from left to right, testifies to a restrictive foramen ovale, a common feature of left-ventricle inflow obstructions. On color flow mapping (b), the entire aorta is seen perfused by unaliased flow despite mitral valve atresia. This is not surprising, because anterograde perfusion of the ascending aorta is possible through a subaortic ventricular septal defect.
AAO ascending aorta, DAO descending aorta, InA innominate artery, LA left atrium, LCA left carotid artery, RA right atrium,
RPA right pulmonary artery

and a transverse section of the aortic root. True
sagittal sections pass through the trabecular part of
the right ventricle anteriorly, the mitral valve, and
the left atrium posteriorly.

The Section Plane
This family of sections is obtained when the chest
is cut sagittally slightly to the left of the midline
of the fetal body or parasagittally with slight angulation toward the left fetal shoulder. The two
extreme planes of these sections are indicated on
the fetal body and a heart diagram in Figure 15.1.
The diagram illustrates how all sections within
these two planes pass through the main pulmonary
artery, the arterial duct, and its junction with the
descending aorta. However, these sections differ
from the structures sectioned inside the body of the
heart. In fact, parasagittal sections include the inlet portion of the right ventricle, the tricuspid valve,

The Normal Morphology
These sections show superiorly the main pulmonary
artery that sweeps posteriorly where it splits into two
branches. The inferior branch is the left pulmonary
artery, and the superior branch is the arterial duct,
which merges into the descending aorta. The vascular continuity between the main pulmonary artery, the
arterial duct, and the descending aorta forms the socalled ductal arch.

S
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a

b

Fig. 15.1 â&#x20AC;˘ The two extreme planes for obtaining a long-axis view of the arterial duct are shown on the fetal body (a)
and on a heart diagram (b). Line 1 indicates the plane along a parasagittal cut, and line 2 indicates the true sagittal section of the fetal body. AoV aortic valve, MV mitral valve, PV pulmonary valve, TV tricuspid valve

156

Echocardiographic Anatomy in the Fetus

When the examining plane is oriented along a true
sagittal plane, an oblique cut of the outflow of the
left ventricle appears in the center of this section. Inferiorly, the left atrium is seen, separated from the
left ventricular outflow by the anterior leaflet of the
mitral valve. Anteriorly, a transverse section of the
right ventricle is displayed apically to the tricuspid
valve and the inlet portion (Fig. 15.2).
When the section plane is parasagittal, a cross
section of the aortic root and its valve is displayed
in the center of the heart, and a section of the two
atria is seen inferiorly. With further clockwise rotation, the plane of this section becomes the short-axis view of the heart at the level of the right ventricular outflow tract.

Sagittal and parasagittal sections close to the
midline of the fetal body are characterized by a
long-axis view of the spine, with a long series of
vertebral bodies displayed in the posterior part of
the section and with the descending aorta in front
of it.

The Normal Echocardiogram – 2D
In the normal fetus, the arterial duct arch arises in a
more anterior position in the chest compared with the
aortic arch. This is because its anterior branch, the
main pulmonary artery, is connected with the infundibulum of the right ventricle, which is the heart’s

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Fig. 15.2 • The fetal thorax is sectioned along a true sagittal plane slightly to the left of the sternum. Superiorly, a longaxis view of the main pulmonary artery and the arterial duct is seen joining the descending aorta (the ductal arch).
The white asterisk indicates the origin of the left pulmonary artery. A cross section of the innominate vein is shown in
the superior part of the mediastinum. The left ventricular outflow tract is seen in the center of the section separated
from the left atrium by the anterior leaflet of the mitral valve. Anteriorly, a transverse section of the right ventricle is
displayed. Posteriorly, a long tract of the descending aorta is seen in front of a longitudinal section of the spine. The
white arrowheads indicate the spinal cord. AD arterial duct, CS coronary sinus, DAO descending aorta, HV hepatic vein,
InV innominate vein, LA left atrium, LB left bronchus, LVOT left ventricular outflow tract, MPA main pulmonary artery,
MV mitral valve, PV pulmonary valve, RV right ventricle

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CHAPTER 15 • The Arterial Duct Long-Axis View

most anterior structure. Consequently, the arterial
duct arch has a wider curvature than that of the aortic arch and is often referred to as having a “hockey-stick” appearance on ultrasound examination. Inferiorly to the pulmonary end of the arterial duct, the
origin of the left pulmonary artery can be imaged.
The most important feature of the ductal arch is that
it does not give origin to the head and neck vessels.
Only the left subclavian artery is often seen to enter
the distal aortic arch (isthmus) above the aortic end
of the arterial duct.
As already stated, parasagittal and sagittal sections differ as to the structures inside the heart that
are displayed together with the arterial duct arch.
In parasagittal sections, the left atrium, the right atrium, the tricuspid valve, and the right ventricle are
seen wrapping around the aortic valve, which is
seen in cross section in a central position. With
high-resolution machines, a portion of the interatrial septum can be imaged between the two atria,
with the flap valve protruding into the left atrium.
Inside the right atrium, the Eustachian valve is often seen, simulating a membrane that divides this
chamber in two portions: the posterior portion,
which receives the inferior vena cava and the hepatic veins, and the anterior portion, the so-called
vestibule, which gives access to the right ventricle
through the tricuspid valve. In parasagittal section,
a short tract of the descending aorta and a limited
number of vertebral bodies can be imaged at the
same time (Fig. 15.3).
When the section plane is along a truly a sagittal plane of the fetal body, the central position is occupied by an oblique cut of the left ventricular outflow tract. Posteriorly, the left atrium is seen, sepa-

rated from the left ventricular outflow by the anterior leaflet of the mitral valve. True sagittal orientation of the scan plane is also characterized by a longaxis view of the descending aorta, which is displayed
for a long tract in front of a row of thoracic and lumbar vertebral bodies (Fig. 15.4a).
In our experience, a true sagittal view of the arterial duct is easier to obtain than a parasagittal view.
To obtain a projection of this type, it is helpful to
start from a transverse view of the fetal thorax. With
the fetus in ventral presentation, the probe must be
placed on the left side of the sternum and the ultrasound beam aligned on the main pulmonary artery
and descending aorta. The long-axis view of the arterial duct is obtained after 90° rotation of the scan
plane (Fig. 15.4b).
Together with its transverse view, the long-axis
view of the arterial duct is useful to assess the size,
shape, and flow of the arterial duct. Together with
the right ventricle outflow view, it allows evaluation
of the right ventricular infundibulum, the pulmonary
valve, and the main pulmonary artery.

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler
With the fetus in dorsoposterior presentation, the arterial duct arch is coded in blue. When the descending
aorta is oriented at a right angle to the ultrasound
beam, the flow is represented with color only in the
main pulmonary artery and arterial duct (Fig. 15.5).
If the approach to the fetal body is more cranial, the
entire course of the descending aorta is seen in col-

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Fig. 15.3 • Long-axis view of the arterial duct obtained with
parasagittal orientation in a normal 28-week gestationalage fetus. The ductal arch is displayed, formed by the main
pulmonary artery, the arterial duct, and the descending
aorta. A cross section of the aortic valve is seen in the center of this view, with the two atria, the tricuspid valve, and
the right ventricle wrapping around. The yellow arrowhead
indicates the flap valve of the atrial septum, which protrudes inside the left atrium. The white arrowhead indicates
the Eustachian valve, between the posterior part (1) and
the vestibule (2) of the right atrium. The asterisk is placed
at the origin of the left pulmonary artery. AD arterial duct,
AV aortic valve, DAO descending aorta, HV hepatic vein,
LA left atrium, MPA main pulmonary artery, PV pulmonary
valve, RA right atrium, RV right ventricle, TV tricuspid valve

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158

Echocardiographic Anatomy in the Fetus
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Fig. 15.4 • Cross-sectional image (a) of the long-axis view of the arterial duct obtained with true sagittal orientation of
the scan plane in a 23-week gestational-age fetus. The “hockey-stick” appearance of the arterial duct arch is visible. The
origin of the left subclavian artery is seen above the junction of the arterial duct with the descending aorta. The asterisk
indicates the origin of the left pulmonary artery. The diagram (b), imitating the transverse view of the arterial duct, illustrates where the probe must be placed and how the beam axis must be oriented to obtain the long-axis view of the arterial duct by 90° rotation of the scan plane. A left parasternal approach on the fetal thorax is needed. AD arterial duct,
DAO descending aorta, LA left atrium, LSA left subclavian artery, LVOT left ventricular outflow tract; MPA main pulmonary
artery, MV mitral valve, PV pulmonary valve, RV right ventricle

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Fig. 15.5 • Color flow mapping from the long-axis view of
the arterial duct in a normal 23-week gestational-age fetus.
This early systolic frame shows a slightly aliased flow at the
level of the pulmonary valve and of the arterial duct. The
Nyquist limit is 42 cm/s. The asterisk indicates the origin of
the left pulmonary artery. AD arterial duct, DAO descending aorta, LA left atrium, LVOT left ventricular outflow tract;
MPA main pulmonary artery, MV mitral valve, PV pulmonary
valve, RV right ventricle

Fig. 15.6 • Pulsed Doppler tracing of the arterial duct flow
in a normal 36-week gestational-age fetus obtained in a longaxis view of the arterial duct. Because of the left paravertebral approach, the arterial duct flow approaches the probe
and therefore is represented as a positive wave. The image
shows the higher systolic waves (S) reaching 140 cm/s and
the smaller diastolic waves (d) below 20 cm/s

CHAPTER 15 • The Arterial Duct Long-Axis View
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Fig. 15.7 • Parasagittal long axis-views of the ductal arch in a 23-week gestational-age fetus with hypoplastic left heart.
On cross-sectional examination (a), the size of the ductal arch is disproportionately large because of redistribution of the
total cardiac output on the right ventricle. The aortic root, seen in cross section, is so small it is difficult to identify. The
asterisk indicates the origin of the left pulmonary artery. Color flow mapping (b) confirms the increased size of the ductal arch, with some aliased flow at the level of the duct. The white arrowheads indicate two small jets of flow from the left
atrium to the right atrium through a restrictive foramen ovale. AD arterial duct, AV aortic valve, DAO descending aorta,
LA left atrium, LSA left subclavian artery, MPA main pulmonary artery, RA right atrium, RV right ventricle, TV tricuspid valve

or. Because the peak velocity of arterial duct flow
reaches the highest values in the fetal circulation, it
is common to see an aliased flow in the arterial duct
in early systole.
The arterial duct flow is characterized by systolic and diastolic anterograde waves. The peak velocity of this vessel reaches the highest value of
the entire fetal cardiovascular system. Due to the
high pulmonary vascular resistance and the reduced
pulmonary perfusion, a large portion of the output
from the right ventricle is diverted through the arterial duct into the descending aorta. The peak acceleration time of the arterial duct’s systolic wave
is higher than that of both the aorta and pulmonary
arteries, reflecting the low resistances of the placenta downstream. Once the systolic wave has returned to baseline, a second anterograde wave, of
much smaller width than the first, is observed during diastole (Fig. 15.6). This wave is thought to be
the result of the rebound of the energy potentially
stored by the walls of the main pulmonary artery
and its branches, which produces a further flow
from the pulmonary artery toward the aorta [1]. The
systolic peak velocity usually varies from less than
50 cm/s at 6 weeks to 130-160 cm/s at the end of
the pregnancy. The diastolic peak velocity for the
same period ranges from close to zero early in gestation to 30-40 cm/s near term. The pulsatility index is rather constant throughout gestation, varying between 1.9 and 3.0 [2].

Duct-Dependent Systemic Circulation
In congenital heart disease with duct-dependent systemic circulation, the arterial duct shows an increased size due to redistribution of the total cardiac output to the right side of the heart. The position and the shape of the arterial duct is usually
normal (Figs. 15.7, 15.8).

Duct-Dependent Pulmonary Circulation
In duct-dependent pulmonary circulation, the arterial
duct frequently shows abnormalities of size, shape, and
origin. When it is normally located, the size is generally reduced and shows an inverted curvature that
lies on a more vertical plane [3]. This abnormal shape
is due to reversed arterial duct perfusion from the aorta (Fig. 15.9). Arterial ducts of this kind cannot be visualized on the standard long-axis view of the arterial duct but can often be seen on a long-axis view of
the aortic arch (Fig. 15.10).
Critical pulmonary valve stenosis or atresia with intact ventricular septum sometimes shows a normalshaped duct. Many authors agree that cases with severe
pulmonary valve stenosis or atresia at term are less severe and have better forward flow in the first part of
pregnancy [4], thus explaining the normal size and shape
of the arterial duct in some these cases (Fig. 15.11).

160

Echocardiographic Anatomy in the Fetus

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Fig. 15.8 â&#x20AC;˘ Long-axis view of the arterial duct in a 33-week gestational-age fetus with a complex type of aortic coarctation. These views are obtained from a left paravertebral approach. Due to the oblique nature of this cut, the aortic and
ductal arches are seen on cross-sectional examination (a). The size of the transverse arch of the aorta is markedly smaller than the size of the pulmonary artery and the arterial duct. On color flow mapping (b), the ductal arch is normally perfused in red,
d whereas the aortic arch is retrogradely perfused in blue through the arterial duct. AD arterial duct, DAO descending aorta, LA left atrium, PA main pulmonary artery, RA right atrium

a

b

Fig. 15.9 â&#x20AC;˘ In the normal heart (a), the arterial duct merges into the descending aorta in a nearly horizontal plane. The
direction of blood flow is from the pulmonary artery to the descending aorta. In pulmonary atresia (b), the arterial duct
frequently is more vertical and the direction of blood flow is from the aortic arch to the pulmonary artery. AAO ascending aorta, DAO descending aorta, PA pulmonary artery

CHAPTER 15 • The Arterial Duct Long-Axis View

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Fig. 15.10 • Long-axis view of the aortic arch in a 27-week gestational-age fetus with pulmonary valve atresia associated with complete atrioventricular septal defect. On cross-sectional examination (a), the arterial duct lies in a more vertical plane coming from the concavity of the aortic arch. Compared with the size of the aortic arch, the duct is relatively
small and shows an inverted curvature. Color flow mapping (b) demonstrates reversed perfusion of the duct from the
aorta. AAO ascending aorta, AD arterial duct, DAO descending aorta, IV innominate vein, T trachea

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Fig. 15.11 • Cross-sectional long-axis view (a) of the arterial duct in a 23-week gestational-age fetus with critical pulmonary
stenosis. The main pulmonary artery is a good size, as is common in this type of congenital valve malformation. Despite
severe obstruction to the pulmonary outflow, the arterial duct maintained a normal curvature. Systolic frame on color
flow mapping (b) shows a tiny jet of forward flow (yellow
(
arrow
w) through the pulmonary valve in early systole. This small
jet is easily overlooked if a high-resolution ultrasound machine with appropriate setting is not employed. Moreover, such
a brief jet is easily missed on moving images and is better identified on frame-by-frame assessment. The main pulmonary
artery is retrogradely perfused through the arterial duct, and this flow is represented in red. Even a very small patency
of the pulmonary valve improves the probability of successful transcatheter balloon dilation and lowers the risk of complication. AD arterial duct, DAO descending aorta, LA left atrium, LVOT left ventricular outflow tract; MPA main pulmonary
artery, MV mitral valve, PV pulmonary valve, RV right ventricle

162

Echocardiographic Anatomy in the Fetus
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Fig. 15.12 â&#x20AC;˘ Parasagittal view of the arterial duct in a 32-week gestational-age fetus with premature duct constriction. Cross-sectional examination (a) is not particularly striking, and this complication is easily missed. Only with careful examination does the aortic end of the arterial duct appear narrowed. This systolic frame on color flow mapping
(b) confirms the narrowing of the arterial duct at its aortic end, where a jet of accelerated flow originates and extends into the descending aorta. A second jet of tricuspid-valve regurgitation is seen inside the right atrium. The
white asterisks indicate the origin of the right and left pulmonary artery. AD arterial duct, AV aortic valve, DAO descending aorta, LA left atrium, MPA main pulmonary artery, PV pulmonary valve, RA right atrium, RV right ventricle,
TV tricuspid valve

The Arterial Duct â&#x20AC;&#x201C; Premature Constriction
or Closure
Arterial duct patency in the fetus is the result of an
active process due to the release of prostaglandins
from the placenta and, to a lesser degree, from the
duct wall.
Premature arterial duct constriction or closure can
occur in the human fetus. Maternal treatment with
prostaglandin synthetase inhibitors can produce fetal
ductal constriction. Indomethacin has been implicated in many published cases with ductal constriction/closure [5-7]. The risk of this complication increases with advanced gestational age and is dose dependent [8]. However, other anti-inflammatory agents
can also cause this effect, blocking the cyclooxygenase enzymes that produce prostaglandins [9, 10]. It
can occur, however, even without exposure to
prostaglandin synthetase inhibitors (Fig. 15.12). Recently, arterial duct constriction in the fetus as been
associated with maternal ingestion of herbal teas and
grape juice during pregnancy [11]. Prenatal ductal
constriction/closure can lead to progressive right ventricular dysfunction, with secondary tricuspid regurgitation, congestive heart failure, and fetal death. Persistent pulmonary hypertension of the newborn has

been linked to in utero arterial duct constriction. Although the long-term prognosis appears to be good
in survivors, there is a risk of neonatal death. Prompt
delivery after diagnosis is advocated to avoid such
complications.
When suspected in the transverse section, ductal constriction or closure must be confirmed in longitudinal sections. False positive images for constriction can be obtained if the section plane does
not pass through the vessel lumen. Suspicion on
cross-sectional images needs to be confirmed by
Doppler assessment [12, 13]. In case of arterial duct
constriction, longitudinal sections are usually the
best way to evaluate the size and flow of the arterial duct and to align the cursor line to the jet for
pulsed or continuous Doppler assessment. In cases
with severe arterial duct constriction, continuous
Doppler system may be necessary, because the maximal velocities of the flow through the narrowed duct
can be greater than 3 m/s (Fig. 15.13). In case of
ductal closure, one must be careful not to mistake
the flow into the left pulmonary artery for the arterial duct flow (Fig. 15.14). Indirect signs of ductal
closure/constriction can be identified from the fourchamber view. These include hypertrophy and dysfunction of the right ventricle and regurgitation of
the tricuspid valve.

CHAPTER 15 • The Arterial Duct Long-Axis View

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b

a
Fig. 15.13 • Continuous-wave Doppler spectrum (a) of the arterial duct jet in the same case shown in Figure 15.7. The
systolic velocity is approximately 3 m/s, well above the normal upper limits for the arterial duct, whereas the diastolic velocity is 1.8 m/s. The small frame (b) indicates the cursor-line position (dashed line)

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Fig. 15.14 • Arterial duct long-axis view in a 29-week gestational-age fetus with complete closure of the arterial duct.
On cross-sectional examination (a), the arterial duct walls are thickened and have a virtual lumen, as in a postnatal
examination. On color flow mapping (b), this complication was overlooked by an experienced examiner, because the
flow into the proximal left pulmonary artery was mistaken for the forward flow into the arterial duct. AD arterial duct,
DAO descending aorta, LA left atrium, LPA left pulmonary artery, LVOT left ventricular outflow tract, MPA main pulmonary
artery, PV pulmonary valve, RV right ventricle

Technique
Visualization of the long-axis views of the aorta and
arterial duct is facilitated in the fetus if one refers to
a transverse section of the upper mediastinum as the
starting point. For instance, the long-axis view of the
aortic arch is obtained from the transverse view of
the fetal thorax by rotating the scan plane 90° when
the ascending and the descending aorta are aligned
with the ultrasound-beam axis. In the normal fetus
in ventral presentation, this alignment is obtained by
placing the transducer on the right parasternal area
(Fig. 16.1).

On the other hand, the long-axis view of the arterial duct is obtained after 90° rotation of the scan plane
when the main pulmonary artery and descending aorta are aligned with the ultrasound-beam axis in a transverse view of the fetal thorax. When the fetus is in ventral presentation, this alignment is possible by placing
the transducer on the left side of the sternum (Fig. 16.2).
In the normal fetus in dorsoanterior presentation, the sagittal view of the aortic arch and the ductal arch is obtained with a left paravertebral approach (Fig. 16.3a). The right paravertebral approach is useful to obtain the bicaval view from
the back (Fig. 16.3b). Figure 16.4 shows a sagittal echocardiographic view of the aortic arch with
left paravertebral approach to the fetal body.

Fig. 16.3 • Diagrams of the arterial duct transverse view with the fetus in dorsoanterior presentation. Sagittal views (a)
of the aortic arch and arterial duct are obtained with appropriate orientation of the scan plane with left paravertebral
approach because the descending aorta is located on the left side of the spine. These views cannot be obtained with
right paravertebral approach (red cross). Conversely, a right paravertebral approach (b) is usually necessary to obtain the
bicaval view from the back and cannot be obtained from the right side of the spine (red cross). AAO ascending aorta, AD
arterial duct, DAO descending aorta, MPA main pulmonary artery

CHAPTER 16 • Special Considerations on the Arterial Duct and Aortic Arch Views

167

b

Fig. 16.4 • Diagram of the arterial duct transverse view with the fetus in dorsoanterior presentation (a). Left paravertebral probe position is necessary to align the ascending and descending aorta with the beam axis. After 90° rotation of
the scan plane, a long-axis view of the aortic arch is obtained, with the spine in anterior position (b). AAO ascending aorta,
DAO descending aorta, RPA right pulmonary artery

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Fig. 16.5 • Green sectors indicate the area of approach to the
fetal thorax that provides transverse sections of the aortic
arch and arterial duct. Yellow sectors indicate the limited areas where the long axis of the aortic arch (1) and arterial
duct (2) are obtained

It is therefore evident that the long-axis view of
the aortic arch and the arterial duct arch is obtained
only from limited positions of the transducer. With
unfavorable fetal presentation, achieving these views
can be an exhausting procedure for the examiner and
the patient. Moreover, the sagittal views of the fetal
thorax are limited by shadows of the ribs and sternum, which is particularly the case with advanced
gestational age. On the other hand, a transverse section of the aortic and arterial duct arches is more easily obtained from a wide range of lateral approaches to the fetal thorax (Fig. 16.5). Better penetration
of the ultrasound beam between intercostal spaces
is often possible, even in third-trimester examinations
(Figs. 16.6, 16.7). However, these views are often
limited by the position of the upper limbs and the
scapulae. Also, it is better to avoid the very anterior portion of thorax because of the noisy shadowing
of the sternum (Fig. 16.8).

Fig. 16.7 • Normal three-vessel view in a 34-week gestational-age fetus with transverse approach on the right side
of the fetal thorax. The normal size, shape, and alignment
of the vessels is shown. To obtain sagittal views of the two
arches would be impossible if the fetal position remains unchanged. AAO ascending aorta, MPA main pulmonary artery,
S spine, SVC superior vena cava

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Fig. 16.8 • This three-vessel view shows shadowing of the
sternum because of the direct approach of the ultrasound
beam to the midline of the fetal thorax. The pulmonary
artery is not defined because it is covered by a strong ultrasound shadow (yellow
(
arrowheads) generated by the sternal cartilage. AAO ascending aorta, MPA main pulmonary
artery, S spine, SVC superior vena cava

CHAPTER

17

The Right Ventricle Outflow View

The Section Plane
Because of the horizontal position of the fetal heart,
sections along its short axis lie on planes close to
a sagittal plane of the fetal body. From a sagittal
plane parallel to the fetal spine, these sections are
obtained with a slight rotation toward the left side
of the fetus, so that the examining plane is from
the right hypochondrium to the left shoulder. By
maintaining this orientation and by translating the
scanning plane leftward on the fetal thorax, a series of sections from the base of the heart to its apex
is obtained.
This short-axis section of the heart is obtained by
sweeping the section plane leftward from the longaxis view of the aortic arch. The section level is in-

dicated in Figure 17.1. Because the aortic root is nearly parallel to the long axis of the heart, the shortaxis view displays the aortic root in cross section
(Fig. 17.1b). Moreover, because the right ventricular outflow is nearly orthogonal to the left outflow,
the right ventricular outflow is seen in long axis,
hence the name of this view. This is because in the
normal heart, the great arteries are wrapped around
one another and their outflows cross (Fig. 17.2).

The Normal Morphology
In the right ventricular outflow view, structures of
the right side of the heart are displayed arranged
around the aortic root, as seen in the center of the
section (Fig. 17.3).

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Fig. 17.1 â&#x20AC;˘ The dashed line indicates the plane of the right ventricular outflow view on the fetal body (a) and on a heart
diagram (b). AO ascending aorta, MV mitral valve, PA main pulmonary artery, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus
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Fig. 17.2 â&#x20AC;˘ This heart diagram shows the nearly orthogonal orientation of the outflow of the left (red arrow)
w and right
(blue arrow)
w ventricle. The major axis of the latter is almost
parallel to the plane of this view (dashed line)

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Fig. 17.3 â&#x20AC;˘ This specimen is sectioned along a parasagittal plane of the fetal body to imitate the outflow view of the right
ventricle. In the center, the aortic root is seen in cross section at the level of its valve. Superiorly, the pulmonary valve is
shown where the infundibulum (bracket)
t joins the main pulmonary artery. Posterosuperiorly, the origin of the right branch
from the main pulmonary artery is seen. Inferiorly, an oblique section of the left and right atrium is seen, with the interatrial septum in between (asterisk).
k Inferoanteriorly, the tricuspid valve, sectioned along its septal (1) and mural (2) leaflets,
connects the right atrium to the inlet portion of the right ventricle. Anteriorly, the right ventricle wraps around the aortic root with its inlet and outlet component (the infundibulum). AOA aortic arch, AOV aortic valve, FO foramen ovale, LA
left atrium, LB left bronchus, MB moderator band, MPA main pulmonary artery, PV pulmonary valve, RA right atrium, RPA
left pulmonary artery, RV right ventricle, TV tricuspid valve

CHAPTER 17 • The Right Ventricle Outflow View

The Normal Echocardiogram – 2D
As stated, most structures of the right heart can be
investigated in this view. These structures include the
right atrium, the tricuspid valve, the infundibulum,
the pulmonary valve, and the main pulmonary artery.
Because the root of the great arteries is imaged, this
view is ideal for measuring the diameter of the root
of the aorta and the pulmonary artery. Moreover, it

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allows assessment of defects of the membranous part
of the interventricular septum and deviation of the infundibular septum. Posteriorly, the main pulmonary
artery is often seen bifurcating into the right pulmonary artery and arterial duct. Behind the aortic root,
a section of the left atrium and the atrial septum is
imaged. With high-resolution equipment, the flap
valve is seen flickering into the body of the left atrium on moving images (Fig. 17.4b). Due to the oblique
orientation of this section relative to the long axis of
the fetus, few vertebral bodies are displayed.

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler

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This view highlights the wide angle between the direction of the inlet and outlet portion of the right ventricle, approximately at right angles to each other.
When the inner curvature of the heart is toward the
apex of the echocardiographic fan, this view is particularly suitable for Doppler assessment of the inflow
and outflow of the right ventricle, with favorable interrogation angle (Fig. 17.5). This allows assessment
of the flow of the tricuspid valve, the right ventricular outflow, and the pulmonary valve (Fig. 17.6).
Figures 17.7-17.11 show some examples of congenital heart disease seen in the right ventricle outflow view.

Fig. 17.5 • This diagram, imitating a right ventricular outflow
view, shows how the inflow and outflow of the right ventricle are investigated with a ventral approach to the fetal heart.
The directions of the inflow and outflow (yellow arrows) of
the right ventricle are approximately at right angles with
each other. AO aorta, PA pulmonary artery, RA right atrium,
RV right ventricle

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Echocardiographic Anatomy in the Fetus

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Fig. 17.6 â&#x20AC;˘ Color flow mapping in ventral presentation in a normal 22-week gestational-age fetus. The diastolic frame (a)
shows the opening of the tricuspid valve, with the right ventricle filling in red. A faint flow is seen in blue filling the right
ventricular outflow, and the pulmonary valve is closed. In this systolic frame (b), the tricuspid valve is closed, and the outflow from the right ventricle is seen in blue filling anterogradely the main pulmonary artery. The flow is slightly aliased at
the level of the arterial duct, where it reaches its highest velocity. AD arterial duct, AOV aortic valve, Ist isthmus of the aorta,
LA left atrium, MPA main pulmonary artery, PV pulmonary valve, RA right atrium, RV right ventricle, S spine, TV tricuspid valve

b
Fig. 17.8 â&#x20AC;˘ Right ventricular outflow view in a 36-week gestational-age fetus with a classic type of tetralogy of Fallot.
The cross-sectional frame (a) shows the subaortic ventricular septal defect (asterisk) with anterior malalignment of
the infundibular septum (arrowhead), which narrows the
outlet toward the pulmonary artery. Although smaller than
the aorta, the diameter of the main pulmonary artery is reasonably good. The systolic frame on color flow mapping (b)
demonstrates the forward flow through the pulmonary
valve with slight acceleration. The blue flow in the ventricular septal defect testifies to a shunt from the right ventricle into the aortic root through the defect. A correlative diagram (c). AO aorta, AOA aortic arch, LA left atrium, MPA main
pulmonary artery, PV pulmonary valve, RA right atrium, RV
right ventricle, S spine, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus

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Fig. 17.9 â&#x20AC;˘ Right ventricular outflow view in a 31-week gestational-age fetus with tetralogy of Fallot with pulmonary
atresia. The cross-sectional frame (a) is similar to the case
shown in Figure 17.8a. However, on moving images, the pulmonary valve is immobile without systolic opening. On color flow mapping (b), the pulmonary valve atresia is confirmed with absent forward flow through the pulmonary
valve and retrograde perfusion of the main pulmonary
artery in red through the arterial duct. Because of a rightsided aortic arch, a cross section of the descending aorta is
seen on the right side of the spine. A correlative diagram
of this congenital heart disease (c). AO aorta, DAO descending aorta, IVC inferior vena cava, LA left atrium, MPA
main pulmonary artery, PV pulmonary valve, RA right atrium, RV right ventricle, S spine, TV tricuspid valve

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CHAPTER 17 â&#x20AC;˘ The Right Ventricle Outflow View

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Fig. 17.10 â&#x20AC;˘ Right ventricular outflow view in a 33-week gestational-age fetus with pulmonary atresia and intact ventricular septum. The cross-sectional image (a) shows a right
ventricle with a reduced cavity and hypertrophic walls. The
membranous septum is intact. Although small, the cavity of
the infundibulum is represented beneath the plane of an
imperforate pulmonary valve. The size of the main pulmonary artery is reasonably good. On color flow mapping
(b), the pulmonary artery is retrogradely perfused through
the arterial duct in red. A correlative diagram (c). AD arterial duct, AOA aortic arch, LA left atrium, MPA main pulmonary
artery, PV pulmonary valve, RA right atrium, RV right ventricle, S spine, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus
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Fig. 17.11 â&#x20AC;˘ Right ventricular outflow view in a 33-week gestational-age fetus with Ebsteinâ&#x20AC;&#x2122;s malformation. The cross-sectional image (a) shows significant dilatation of the right atrium. On moving images, the tricuspid valve leaflets appear
elongated and dysplastic. The anterolateral leaflet (1) is inserted normally, whereas the septal leaflet (2) is displaced, reaching the plane of the pulmonary valve. The pulmonary artery shows a reasonably good size despite the fact the pulmonary
valve cusps do not show a clear systolic opening. On color flow mapping (b) the main pulmonary artery is perfused retrogradely in red through the arterial duct. A regurgitating jet (yellow
(
arrow
w) indicates the functional nature of the pulmonary valve atresia. The turbulent flow (yellow-blue
(
) in the right atrium is produced by a severe tricuspid regurgitation,
better assessed in the four-chamber view. AOA aortic arch, LA left atrium, MPA main pulmonary artery, PV pulmonary valve,
RA right atrium, RV right ventricle, S spine, TV tricuspid valve

CHAPTER

18

The Left Ventricle Short-Axis View

The Section Plane

The Normal Morphology

This view is obtained with the scan plane perpendicular to the long axis of the left ventricle. Because
of the horizontal position of the fetal heart, these
views lie on planes close to the sagittal plane of the
fetal body. In normal hearts, this is obtained by cutting the fetal body on a parasagittal plane slightly
rotated to the left shoulder. Two sections, which are
easy to recognize, are: (1) at the level of the atrioventricular valves, and (2) at the level of the papillary muscles of the left ventricle. These sections
can be sequentially obtained by translating the scan
plane from the midline toward the left side of the
fetal body (Fig. 18.1).

In the normal fetus, the short-axis view of the left ventricle shows the heart lying on the diaphragm, with
the left lobe of the liver and the stomach underneath
and the left lung posteriorly. When the heart sits in its
normal position, the spine is not seen posteriorly, but
a section of the left thoracic cage is visible (Fig. 18.2).

The Level of the Mitral and Tricuspid Valves
When the scan plane is close to the atrioventricular junction, the different morphologic features of
the two ventricles are shown: anteriorly, the right

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Fig. 18.1 â&#x20AC;˘ Planes of the short-axis views of the left ventricle are illustrated on the fetal body (a) and on a heart diagram
(b). Line 1 indicates the section at the level of the atrioventricular valves, and line 2 is at the level of the papillary muscles
of the left ventricle. AOV aortic valve, MV mitral valve, PV pulmonary valve, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus
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Fig. 18.2 â&#x20AC;˘ This specimen is sectioned along a parasagittal plane on the left side of the fetal body. Although the section
is not exactly in the short-axis plane of the left ventricle, the image shows the position of the heart on the diaphragm
(white arrowheads), with the stomach and the left lobe of the liver underneath. Behind the heart, a sagittal section of the
left lung is seen bordered posteriorly by the thoracic cage ((yellow arrowheads). AG adrenal gland, K kidney, LV left ventricle, RV right ventricle, St stomach

ventricle with semilunar shape and posteriorly, the
left ventricle with a more circular section. The two
atrioventricular valves reveal their different characteristics: the tricuspid valve with three leaflets and
septal insertions, and the mitral valve with two
leaflets and without insertion on the ventricular septum. The inlet portion of the interventricular septum
is seen between the two atrioventricular valves, with
a flattened appearance due to equal ventricular pressure. It is quite common that the short-axis views
of the left ventricle at this level also shows the junction of the infundibulum with the main pulmonary
artery and its homonym valve (Figs. 18.3, 18.4).
Although this view is less intuitive than the fourchamber view to inexperienced examiners, it is very
useful for assessing the type of atrioventricular connection and disproportions between the ventricles and
their respective atrioventricular valves.

The Level of the Papillary Muscles
In short-axis sections of the heart more toward the
apex, the different shape of the ventricles is still ap-

preciated, but the infundibulum is no longer visible (Fig. 18.5). The subvalvular apparatus of the mitral valve shows two papillary muscles in the left
ventricle and a transverse section of the moderator
band in the right ventricle. When the atrioventricular valves are inserted normally at their atrioventricular junction, the tricuspid and mitral valve
leaflets are not imaged at this level. Between the
right and the left ventricle, the midportion of the
interventricular septum is seen. Therefore, the
whole trabecular and perimembranous portion of the
interventricular septum is investigated with this
family of views by moving the scanning plane from
the base to the apex of the heart. Because the septum is imaged at right angle to the ultrasound beam,
these sections are particularly reliable in distinguishing true defects of the septum from false
dropouts. Moreover, ventricular septal defects can
also be assessed on color flow mapping, because
the flow through the septal defect is mostly parallel to the ultrasound beam.
Figures 18.6-18.12 are examples of short-axis
views of the left ventricle in some congenital heart
diseases.

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CHAPTER 18 • The Left Ventricle Short-Axis View
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Fig. 18.3 • In this specimen, the heart is sectioned to imitate the short-axis view of the left ventricle at the level of
the mitral and tricuspid valve leaflets. The different morphologic features of the ventricles are shown: crescent-like
for the right ventricle, and more circular for the left ventricle. The close relationship of the tricuspid valve septal leaflet
((yellow arrowhead) with the right side of the interventricular septum is demonstrated, whereas the left side is free from
the mitral valve apparatus (white arrowhead). LV left ventricle, MV mitral valve, RV right ventricle, TV tricuspid valve

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Fig. 18.4 • Echocardiograph of a normal short-axis view
of the heart at the level of the mitral and tricuspid valves.
The heart is lying on the diaphragm (open arrowheads),
with the stomach and left lobe of the liver underneath. Posteriorly, a sagittal section of the left lung is imaged. The
different relationship of the mitral and tricuspid valves with
the ventricular septum is demonstrated. The anterior ventricle gives rise to the infundibulum and the pulmonary
artery, with the pulmonary valve in between. Inf infundibulum, LV left ventricle, MV mitral valve, PV pulmonary
valve, RV right ventricle, St stomach, TV tricuspid valve, VS
ventricular septum

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Fig. 18.5 • Short-axis view of the left ventricle at the level
of the papillary muscles (asterisks). The open arrowheads indicate the diaphragm. The infundibulum is no longer seen
at this level. LV left ventricle, RV right ventricle, St stomach,
VS ventricular septum

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Echocardiographic Anatomy in the Fetus

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Fig. 18.6 â&#x20AC;˘ Short-axis view of the left ventricle at the level of the atrioventricular junction in a 24-week gestational-age
fetus with atrioventricular septal defect with atrial and ventricular component (a). A correlative diagram (b). This section
shows an en face view of the common atrioventricular valve (open arrowheads) opening across a defect in the inferior
part of the ventricular septum (asterisk).
k On moving images, the anterior bridging leaflet of the common valve is attached
to the septum, as in Rastelli classification type A. LV left ventricle, MPA main pulmonary artery, RV right ventricle, VS ventricular septum

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Fig. 18.7 â&#x20AC;˘ Short-axis view of the heart in a 28-week gestational-age fetus with atrioventricular septal defect and atrial
component only. This cross-sectional view (a), at the level of the atrioventricular junction, shows two separate atrioventricular-valve orifices. However, both the right and left components of the atrioventricular valve show insertion toward
what seems to be the ventricular septum. This, in reality, is a thin tongue of valvular tissue (asterisk)
k dividing the two atrioventricular valve components. This is a case with normal karyotype and familial recurrence, the father being affected
by an identical congenital heart disease. However, this type of congenital heart defect may also be associated with chromosome anomalies. LV left ventricle, LAVV left atrioventricular valve, RAVV right atrioventricular valve, RV right ventricle,
St stomach

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CHAPTER 18 • The Left Ventricle Short-Axis View
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Fig. 18.8 • Short axis-views of the left ventricle in a 33-week gestational-age fetus with Ebstein’s malformation of the tricuspid valve. On cross-sectional examination (a), the left ventricle is imaged at the level of the papillary muscles. Nevertheless, the anterolateral leaflet of the tricuspid valve (open arrowheads) is still visible inside the cavity of the right ventricle. This indicates the apical displacement of the tricuspid valve leaflets, which also appear tethered to the corresponding
wall of the right ventricle. Ascites is seen below the diaphragm. On color flow mapping (b), the yellow arrow indicates the
origin of a significant regurgitant jet of tricuspid valve, which is the cause of fetal hydrops. LV left ventricle, RV right ventricle, VS ventricular septum

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Fig. 18.9 • Short-axis view at the level of the atrioventricular valves in a 34-week gestational-age fetus with congenitally corrected transposition. This view demonstrates the inverted position of the ventricles and their respective atrioventricular valves. The posterior ventricle is morphologically right, with a crescent-like morphology and the atrioventricular
valve attached to the interventricular septum. The anterior ventricle is morphologically left, with a more circular shape
and the atrioventricular valve unattached to the septum. mLV morphologically left ventricle, mRV morphologically right
ventricle, MV mitral valve, St stomach, TV tricuspid valve, VS ventricular septum

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Echocardiographic Anatomy in the Fetus

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Fig. 18.10 â&#x20AC;˘ Short-axis section at the level of the atrioventricular junction in a 25-week gestational-age fetus with tricuspid atresia (a) and a correlative diagram (b). This section shows a single, bileaflet, atrioventricular valve indicative of
a mitral valve, opening into a large, posterior left ventricle. The rudimentary right ventricle, in anterosuperior position,
lacks its atrioventricular valve. The large ventricle and the rudimentary ventricle communicate through a wide ventricular septal defect (asterisk). The outflow toward the arterial vessel (not seen in this image), committed to the rudimentary ventricle, is unobstructed. LV left ventricle, MV mitral valve, RV right ventricle, St stomach

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Fig. 18.11 â&#x20AC;˘ Short-axis section at the level of the atrioventricular junction in a 36-week gestational-age fetus with double-inlet left ventricle (a) and a correlative diagram (b). This cut shows the univentricular atrioventricular connection in
this case, with the two atrioventricular valves opening into the large cavity of the left ventricle (bracket). The left ventricle communicates with a rudimentary right ventricle, in anterosuperior position, through a restrictive ventricular septal
defect (asterisk). The outflow toward the arterial vessel connected with the rudimental ventricle is severely impaired. Correlative diagram (b). LV left ventricle, MV mitral valve, RV right ventricle, St stomach, TV tricuspid valve

CHAPTER 18 â&#x20AC;˘ The Left Ventricle Short-Axis View

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Fig. 18.12 â&#x20AC;˘ Short-axis view at the level of the papillary muscles in a 34-week gestational-age fetus with a small, midmuscular ventricular septal defect. On cross-sectional examination (a), this view looks entirely normal. The ventricular septal defect cannot be identified. On color flow
mapping (b), the flow in blue shows a right to left shunt
through the small trabecular defect. A correlative diagram
(c). LV left ventricle, RV right ventricle, St stomach, VS ventricular septum, VSD ventricular septal defect

PART II
Echocardiographic Projections
A Transverse Views of the Fetal Body

CHAPTER

19

The Left Ventricle Long-Axis View

The Section Plane

The Normal Morphology

This projection lies on an intermediate plane, between the transverse and sagittal plane of the fetal
body, in a plane that runs from the left hypochondrium to the right shoulder. The standard long-axis
view passes through the long axis of the left ventricle, hence its name. It is obtained by rotating the
transducer 90Â° from the apical four-chamber view
and tilting it toward the right shoulder (Fig. 19.1).
In the fetus, where the proximal ribs and part of the
sternum are not ossified, this view can be obtained
even from the anterior part of the chest.

The parasagittal orientation of this plane is better
appreciated in sections of the whole fetal body,
where abdominal and thoracic structures are displayed (Fig. 19.2). In the left inferior part of these
cuts, the left lobe of the liver and the stomach are
usually seen below the diaphragm. Posteriorly, an
oblique section of the left lung is seen above the
diaphragm, with the descending aorta and esophagus in the posterior part of mediastinum. As to the
heart, a whole section of the left atrium and left ventricle in its full length is usually shown; therefore,

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Fig. 19.1 â&#x20AC;˘ Section plane of the long-axis view of the left ventricle is shown on the fetal body (a) and a heart diagram
(b). The image of the fetal body shows how the section plane is oriented from the left hypochondrium to the right upper part of the chest. AOV aortic valve, MV mitral valve, PV pulmonary valve, TV tricuspid valve

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Echocardiographic Anatomy in the Fetus

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Fig. 19.2 â&#x20AC;˘ Fetal body sectioned to imitate the long-axis view of the left ventricle. The parasagittal orientation of this section is appreciated in this image, where abdominal and thoracic structures are displayed at the same time. In the bottom
left, the left lobe of the liver is seen below the diaphragm (open arrowheads) and the inferior lobe of the left lung above.
In the upper right, the aortic root and innominate vein, structures of the right profile of the heart, are displayed. The left
atrium and ventricle are seen in their full length. The continuity between the interventricular septum (white bracket) and
the anterior wall of the aortic root and between the anterior leaflet of the mitral valve and posterior wall of the aorta is
appreciated. In the posterior part of the mediastinum, from left to right, respectively, an oblique section of the descending aorta, the esophagus, and the right bronchus is seen. AAO ascending aorta, AOV aortic valve, DAO descending aorta, E
esophagus, IV innominate vein, LA left atrium, LV left ventricle, MV mitral valve, RB right bronchus, RPA right pulmonary
artery, RVOT right ventricular outflow tract, S spine, T thymus

this projection is also called the two-chamber view.
The perimembranous and anterior parts of the interventricular septum are displayed together with
the origin of the arterial vessel from the left ventricle. In the normal heart, the ascending aorta
sweeps anteriorly and rightward from the left ventricle. Continuity of the anterior wall of the aorta
with the interventricular septum and the posterior
wall with the anterior leaflet of the mitral valve are
appreciated. Anteriorly to the ventricular septum,
the right ventricular outflow tract is seen, lying almost perpendicular to the left outflow tract. This
view allows appreciation of the narrow angle between the inflow and outflow of the left ventricle,
separated only by the anterior leaflet of the mitral
valve (Fig. 19.3).

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Fig. 19.3 â&#x20AC;˘ This specimen of an isolated heart is sectioned
to imitate the long-axis view of the left ventricle. The yellow arrows show orientation of inflow and outflow of the
left ventricle, separated only by the anterior leaflet of the
mitral valve (white arrowhead) and with a narrow angle between the two. The right superior sweep of the ascending
aorta is appreciated. AAO ascending aorta, AV aortic valve,
LA left atrium, LV left ventricle, MV mitral valve, RVOT right
ventricular outflow tract

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CHAPTER 19 • The Left Ventricle Long-Axis View
Fig. 19.4 • Long-axis view of the left ventricle in a normal 22week gestational-age fetus. In the left-inferior part of this section, the stomach is seen below the diaphragm. The left atrium and left ventricle are imaged in the central part, with the
mitral valve in between. The aortic root is seen sweeping superiorly and to the right beneath the innominate vein, which
is seen in cross section. Anteriorly, an oblique section of the
right ventricular outflow tract is seen behind the anterior thoracic wall. Posteriorly, the descending aorta is displayed between the left atrium and the spine. In the central part of the
image, the arrowhead indicates the membranous portion of
the interventricular septum where subarterial defects are located. The mitroaortic and septal-aortic continuity is clearly
demonstrated. AAO ascending aorta, AOV aortic valve, DAO descending aorta, IV innominate vein, LA left atrium, LV left ventricle, MV mitral valve, RB right bronchus, RPA right pulmonary
artery, RVOT right ventricular outflow tract, St stomach

The Normal Echocardiogram – 2D
Most structures described in the morphological section can be evaluated by ultrasound (Fig. 19.3). The
long-axis view of the left ventricle is particularly useful in assessing the inlet and outlet portion of the left
ventricle. Moreover, defects in the anterior trabecular and subarterial portions of the interventricular septum can be investigated. When obtained with transverse orientation (Fig. 19.4), this view is the most
reliable echocardiographic projection to assess the degree of arterial overriding in subarterial defects, because this part of the septum and the arterial root are
seen nearly at a right angle to the ultrasound beam.

The Normal Echocardiogram – Color Flow
Mapping and Pulsed Doppler

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When obtained with the cardiac apex toward the
echocardiographic fan, this section is ideal for color
flow mapping and pulsed Doppler assessment of the
inflow and outflow of the left ventricle with favorable Doppler interrogation angle (Fig. 19.5). Pulsed
Doppler tracing on this view is very similar to that
described in the section on the five-chamber view.
Figures 19.6-19.14 are examples of congenital
heart disease shown in the long-axis view of the left
ventricle.
The long-axis view of the left ventricle with transverse orientation is particularly suitable for fetal cardiac rhythm assessment with the M-mode and color
M-mode techniques. The cursor line must be aligned
in such a way as to intercept the atrial wall, to asses
atrial contraction, and through the aortic root where the
opening of the aortic valve testifies to ventricular contraction. Figure 19.15 shows one example of normal
color M-mode tracing obtained from this projection.

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Fig. 19.5 • Long-axis view of the left ventricle in a 23-week
gestational-age fetus with apical presentation. The diastolic
frame (a) shows the inflow of the left ventricle through the
mitral valve (red). The aortic valve is closed. In the systolic
frame (b), the outflow from the left ventricle is shown filling the aortic root through the homonym valve (blue). The
mitral valve is closed. AAO ascending aorta, AOV aortic valve,
LA left atrium, LV left ventricle, MV mitral valve

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Echocardiographic Anatomy in the Fetus
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Fig. 19.6 â&#x20AC;˘ Long-axis view of the left ventricle in a 21-week
gestational-age fetus with subaortic ventricular septal defect associated with interruption of the aortic arch. On crosssectional examination (a), a large subaortic ventricular septal defect (asterisk) is seen. The aortic root is relatively small.
This is caused by the posterior deviation of the infundibular septum diverting blood from the left ventricle to the right
ventricle through the defect and obstructing the forward
flow into the aorta. The descending aorta is on the right side
of the spine, anticipating a right aortic arch. On moving images with color flow mapping (b), the shunt in red at the level of the defect of the ventricular septum is from left to right
throughout the cardiac revolution, indicative of significant
obstruction to left ventricular outflow. This is confirmed by
the faint blue forward flow into the aortic root through the
homonym valve. Correlative diagram (c) showing a subarterial ventricular septal defect with posterior malalignment
of the infundibular septum (yellow arrowhead). AAO ascending aorta, DAO descending aorta, LA left atrium, LV left
ventricle, RV right ventricle, S spine

Fig. 19.8 • Long-axis view of the left ventricle in a 31-week gestational-age fetus with tetralogy of Fallot and pulmonary
atresia. The cross-sectional view (a) shows an enlarged aortic root overriding on a subarterial ventricular septal defect
(asterisk). The aortic root is enlarged. On color flow mapping (b), both the left and right ventricles are seen ejecting (blue)
into the aorta through the ventricular septal defect. AAO ascending aorta, DAO descending aorta, LA left atrium, LV left
ventricle, MV mitral valve, RV right ventricle, S spine

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Fig. 19.9 â&#x20AC;˘ Long-axis view of the left ventricle in a 31-week
gestational-age fetus with common arterial trunk type 1. On
cross-sectional examination (a), a large arterial root overriding a subarterial ventricular septal defect (asterisk) is
shown. The ascending aorta and pulmonary artery originate
from this common trunk. On color flow mapping (b), the left
and the right ventricle are seen ejecting into the common
arterial trunk, which represents the single outlet from both
ventricles. The common origin of the ascending aorta and
pulmonary artery is demonstrated. Diagram (c) in the longaxis view of the left ventricle imitating a common arterial
trunk of this type. AAO ascending aorta, AT arterial trunk, DAO
descending aorta, LA left atrium, LV left ventricle, PA pulmonary artery, RV right ventricle, S spine

Fig. 19.11 • Long-axis view of the left ventricle in a 32-week gestational-age fetus with transposition of the great arteries.
On cross-sectional examination (a), the orientation of the root of the arterial vessel, committed to the left ventricle, arouses suspicion of transposition of the great arteries because it sweeps posteriorly, in the opposite direction of a normally located aorta. Moreover, the two great arteries show a parallel course in their first tract. The subarterial ventricular septum
looks intact. Color flow mapping (b) highlights the parallel course of the two great arteries. AAO ascending aorta, DAO descending aorta, LA left atrium, LV left ventricle, MPA main pulmonary artery, MV mitral valve, RV right ventricle, S spine

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Fig. 19.12 • Long-axis view of the left ventricle in a 37-week gestational-age fetus with Ebstein’s malformation and regurgitation of the tricuspid valve. On cross-sectional examination (a), the left heart chamber seems unaffected in this
case. On moving images, the foraminal flap constantly protrudes inside the left atrium (yellow arrowhead) because of the
high right-to-left shunt. A portion of the tricuspid valve leaflet is seen displaced into the right ventricular outflow tract.
In this systolic frame, color flow mapping (b) shows in yellow the regurgitant jet, which originates at the level of the displaced tricuspid valve. The ascending aorta has an increased anterograde flow because of the redistribution of flow from
right to left at the level of the foramen ovale. AAO ascending aorta, LA left atrium, LV left ventricle, MV mitral valve, RVOT
right ventricular outflow tract, TV tricuspid valve, S spine

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R-S

P

b

a

Fig. 19.13 â&#x20AC;˘ Long-axis view of the left ventricle in a 30-week gestational-age fetus with tricuspid valve atresia and discordant ventriculoarterial connections. On cross-sectional examination (a), the left atrium is committed to a large, morphologically left ventricle through a normal mitral valve. There is a rudimentary right ventricle in anterosuperior position. The two ventricles communicate through a small ventricular defect (asterisk). Although this view does not show
any characteristic features that allow one to distinguish which artery is which, these arteries show a parallel course indicative of an anterior aorta. The ventriculoarterial connections are therefore discordant. The diameter of the ascending aorta is relatively small compared with the pulmonary artery. Color flow mapping (b) shows a normally competent
mitral valve with apparently unobstructed systolic flow in blue into the two great arteries. AAO ascending aorta, DAO
descending aorta, LA left atrium, LV left ventricle, MPA main pulmonary artery, MV mitral valve, RV right ventricle, S spine,
St stomach

A

L-I

a

R-S

P

A

L-I

R-S

P

b

Fig. 19.14 â&#x20AC;˘ Long-axis view of the left ventricle in a 37-week gestational-age fetus with double-inlet left ventricle and
discordant ventriculoarterial connection. On cross-sectional examination (a), this view is very similar to the case in Fig.
19.12. In fact, tricuspid atresia and double-inlet left ventricle cannot be distinguished by this view. There is a large, morphologically left ventricle and a rudimentary right ventricle in superoanterior position. The two ventricles communicate through a small ventricular defect (asterisk). The left ventricle is committed to a large pulmonary artery, which bends
posteriorly and shows early bifurcation. The ascending aorta, which originates from the rudimentary ventricle, is significantly smaller than the main pulmonary artery. A complex type of aortic coarctation is associated. Color flow mapping (b) confirms the disproportion in size between the two arterial vessels. AAO ascending aorta, DAO descending aorta, LA left atrium, LPA left pulmonary artery, LV left ventricle, MPA main pulmonary artery, MV mitral valve, RV right ventricle, S spine, St stomach

CHAPTER 19 â&#x20AC;˘ The Left Ventricle Long-Axis View

a

195

b

Fig. 19.15 â&#x20AC;˘ Fetal thorax approached from the anterior side. In a long-axis view of the left ventricle (a), the cursor line is
placed across the aortic root first and the left atrium second. Therefore, these structures are represented in this order,
from top to bottom, in the M-mode tracing (b). Contractions of the left atrial wall are clearly seen (A), followed by regular ventricular contractions, indicated by the opening of the aortic valve (V). The systolic flow through the aortic valve is
easily demonstrated (blue) by color M-mode tracing. AO aorta, LA left atrium, LAW left atrial wall

Introduction
In the last 10 years, 3D and live 3D ultrasound –
also called 4D ultrasound (3D/4D) – became popular in prenatal diagnosis but focused mainly on the
demonstration of the fetal face and other external
fetal body parts (hands, feet, etc.). The use of the
3D/4D in assessing the fetal heart evolved rapidly
with the advent of the new technique called spatial
and temporal image correlation (STIC), which enabled acquisition of a volume data set with information pertaining to the beating fetal heart [1, 2].
Matrix transducers for live 4D examination are already available, but the resolution is still too low to
be routinely used in fetal studies, and the expenses
are still high.
A detailed fetal echocardiogram includes visualization of different cross-sectional planes, either as
parallel transverse slices or oblique short- and longaxis views [3, 4], as shown in the different chapters
of this book. With a systematically segmental approach, venoatrial, atrioventricular, and ventriculoarterial connections are assessed. The use of color Doppler completes the examination in confirm-

ing the regular blood flow at the level of the valves,
chambers, and vessels [5]. Such planes on 2D or color Doppler are today acquired online during live examination but could be generated off-line from a 3D
volume data set [5-7].
This chapter discusses the use of 3D/4D fetal
echocardiography in assessing normal cardiac anatomy, and the potential of its application in fetuses with
cardiac defects is emphasized.

Technical Principles of 3D/4D Fetal
Echocardiography
When 3D ultrasound is used, three steps should be
considered separately: volume acquisition, volume
display, and volume manipulation (Table 20.1).

In this acquisition, still images are stored as a volume data set, and neither heart rate nor motion is considered during acquisition and rendering. A quick, instead of slow, rapid volume acquisition enables motion artefacts to be avoided and provides acceptable
images. This technique cannot be used for assessing
events related to the heart cycle or to myocardial wall
or valve movement. However, size and relationship
of cardiac structures are valuable for diagnostic purposes. This static 3D gray scale can be combined with
color Doppler, but we prefer to use it with uniform
(one color) power Doppler or B-flow. For such purposes, the problem of motion artefacts appears to be
insignificant in vascular 3D visualization, especially when attention is taken to reduce vessel pulsation
during acquisition [8]. This is achieved by increasing the persistence of color Doppler and reducing the
gain.

Planes: One Plane, Multiplanar Orthogonal,
and Multiplanar Tomography

Real-Time 3D (Direct Volume Scan Real Time: Online 4D)
This is achieved either with a mechanical 2D transducer with rapid acquisition of 20-30 volumes/s or
with a matrix 3D transducer, which allows real-time
dynamic 3D evaluation. Both techniques have limitations in image resolution, frame rate, and lack of
combination with color Doppler. In the future, when
computer technology improves, they may partially
replace STIC acquisition.

STIC (Indirect Volume Scan, Motion Gated: Off-Line 4D)
Volume STIC acquisition is a slow acquisition of
image slices (duration 7.5-15 s) that allows acquisition of numerous planes, including additional information from a whole cardiac cycle. Spatial and
temporal image correlation calculates the mean
heart rate acquired, and images in the volume are
rearranged according to their temporal event within the heart cycle. This slice-reconstruction method
is completed directly after a volume scan, and the
4D information is available within seconds. The displayed volume includes a single “hypothetical”
heart cycle, which is reconstructed from single selected images at the different intervals of the heart
cycle [1, 2, 6, 9]. Therefore, STIC cannot be applied when ectopic beats are present. STIC can be
used with gray-scale fetal echocardiography but can
be also combined with color Doppler, power
Doppler, B-flow, etc.

A 3D volume data set contains digital information
of the cardiac structures and their spatial arrangement. In addition, STIC volume contains information on the temporal relationship of the cardiac structures. Thus, from a 3D/4D data set, cross-sectional
views can be obtained at any desired orientation, direction, and depth. In a STIC volume, the reconstructed cardiac volume is displayed as a single hypothetical real-time cardiac cycle played in a cine
loop. The loop may also be played in slow motion
or stopped at any time for detailed analysis of specific phases of the cardiac cycle.
In such a volume data set, each plane of interest
(“any plane”) can be demonstrated by scrolling
through the volume and orienting the views to obtain the plane of interest. In a good volume, the fourchamber, five-chamber, transverse, and long-axis
views of the arterial duct and aortic arch, the threevessel and tracheal view, etc., can be visualized offline both in cine loop or as still images. The display
format (Fig. 20.1) can be either the single-plane view
or a multiplanar view showing three planes perpendicular to each other, or multiplanar tomography
imaging showing parallel slices of the heart cavities
and vessels.
The main limitations of reconstructed views are,
on one hand, lower image quality in comparison with
originally acquired 2D images and, on the other hand,
dependency on possible artefacts. Such artefacts can
be caused by fetal or maternal movements during acquisition, by shadowing in the region of interest, or
by inaccurate volume reconstruction when acquisition time is too long or too short.
Studies on multiplanar analysis from a cardiac cycle at a remote station using STIC volume acquisition were shown to be reliable in assessing the different cardiac planes [6, 7], in screening studies [10],
and in evaluating fetal cardiac anomalies [2, 7, 11,
12]. The advantages of using such a volume for an
Internet link evaluation are emphasized as well,
showing potential for a second opinion in the future
[13]. Efforts were made recently to standardize the
fetal cardiac examination on 3D, and the possibility
of an automated cardiac image analysis from a volume data set was proposed [14, 15].
Color and power Doppler were added to grayscale STIC technology, permitting possible assessment of hemodynamic changes throughout the cardiac cycle in the different cardiac cavities. Advan-

a
c
Fig. 20.1 â&#x20AC;˘ From a 3D or spatial and temporal image correlation (STIC) volume of a fetal heart, it is possible to display on
postprocessing one single plane (a), which can be arbitrarily chosen by the examiner. The display can be multiplanar orthogonal planes (b) with one transversal (1), one longitudinal (2), and one coronal (3) plane, as well as multiplanar tomography view (c) with parallel slices, here seen as transversal planes. In a STIC volume, the period within the cardiac cycle can be selected also

tages and limitations of this technique have been reported elsewhere [2], but once a volume is properly acquired, display in the tomographic mode [12]
provides rapid information on the three essentials
planes in color Doppler, namely, the four-chamber,
five chamber, and three-vessel trachea views (compare Figure 20.2 of a normal heart with Figure 20.3
of a heart with transposition of the great arteries).
Generally, fetal echocardiography is performed by
obtaining numerous planes, such as transverse,
oblique, and longitudinal cross sections, as demonstrated in this book.
For the obstetrician and sonographer not very familiar with these cardiac planes adapted from pediatric and adult cardiology, it has been shown that
the main information for a cardiac exam can also
be achieved by obtaining parallel transverse views
[3, 4, 5, 16]. Such parallel transverse views are ideally demonstrated from a 3D/4D volume data set

using the tomographic display (Figs. 20.1, 20.2).
This approach was shown to demonstrate at a glance
cardiac anomalies affecting the four-chamber planes
as well as conotruncal anomalies involving transverse views of the upper mediastinum, such as the
three-vessel view and the aortic arch transverse
view [11, 12, 17].

Rendering
Surface Mode
In surface-mode rendering, cardiac cavities are well
visualized due to the different echogenicity of blood
and cardiac walls. The render view direction (green
line in Figure 20.4) is placed within the heart as a
thick slice. If the slice is too slim, cardiac walls are
emphasized, but the impression of a volume image

Fig. 20.4 • Volume rendering in surface mode.
If the slice (3D box)
x is chosen narrow (a) the image does not show the same 3D effect as if the
box is larger (b) and includes the inferior wall of
the ventricles

is lacking (Fig. 20.4). The render view line is placed
wherever the examiner wishes, and typical views of
the upper abdomen (Fig. 20.5), the four-chamber
view, the left and right ventricular outflow tract, and
the arterial duct and aortic arch transverse views
(Fig. 20.6) are demonstrated. Fetal cardiac anomalies
are well demonstrated in these views, as shown for
the atrioventricular septal defect (Fig. 20.7a) and the
hypoplastic left-heart syndrome (Fig. 20.7b).
Besides the typical views used in 2D echocardiography, this technique allows reconstruction of
new views, providing new insights into the normal
and abnormal fetal heart. One possibility is to place
the render view direction into the atrium and ventricle to visualize en face the atrial and ventricular
septum from the left or right side (Figs. 20.8, 20.9).
In the future, this view may allow better assessment
of the size and shape of a ventricular septal defect
(Fig. 20.9b) or other septal or valvular anomalies.
In another view, the “base of the heart view” [18],
the render view direction is placed in the atria at
the level of the valves and enables the en face view
of both atrioventricular and semilunar valves (Fig.
20.10). This view may be helpful in demonstrating
the common atrioventricular valve in atrioventricular septal defect (Fig. 20.11). In one study, this
view was shown to help differentiate the different
Rastelli types in fetuses with atrioventricular septal defect [19]. This view is also helpful in demonstrating the caliber and relative position of the great

arteries, as found in transposition of the great arteries (Fig. 20.12) or in double-outlet right ventricle and other congenital heart diseases [18]. In a recent study on fetuses with transposition of the great
arteries, this view used in combination with color
Doppler identified the different patterns of position
of the great arteries [20].

Glass-Body Mode with Color Doppler
Volume acquisition combining 2D and color (or
power) Doppler provides a volume data set with
structural and hemodynamic information of the
fetal heart [2]. Volume data can be rendered in three
ways: either gray scale information alone (see
Surface Mode), color information alone, or the
combination of both as a so-called “glass-body”
mode (Fig. 20.13) [2]. A prerequisite for good volume is optimal presetting of color during 2D scan
before acquiring a volume. One of the main application fields of this mode is to demonstrate the
great-vessel arrangement. The clinical use of such
new techniques, however, remains to be evaluated: Using 3D power Doppler ultrasound, we recently demonstrated the aberrant origin of the left
and right subclavian artery in fetuses [8]. Figure
20.14 shows a heart seen from the anterior, with
both chambers and crossing arteries and a trabecular ventricular septal defect.

204

Echocardiographic Anatomy in the Fetus
b

a

Fig. 20.5 â&#x20AC;˘ Three-dimensional surface view of the upper abdomen (a) and four-chamber view (b). In the upper abdomen
view (a), the stomach, descending aorta, inferior vena cava, and intrahepatic umbilical vein are demonstrated. In the fourchamber view, the cardiac axis points to the left, the descending aorta is on the left of the spine, and the right and left
atria are well visualized, as are the right and left ventricles. DAO descending aorta, IVC Inferior vena cava, LA left atrium,
LV let ventricle, RA right atrium, RV right ventricle, St stomach, UV umbilical vein

Fig. 20.8 • En face view of the interventricular septum. The 3D box is placed over the interventricular septum (a), with
the rendering view from the right side (green line and opened arrow with eye symbol). Visualization of the right atrium
with foramen ovale and the tricuspid valve (b) is seen, as well as the complete area of the interventricular septum (dashed
line) within the right ventricle. FO foramen ovale, IVS interventricular septum, RA right atrium, RV right ventricle, TV tricuspid valve

206

Echocardiographic Anatomy in the Fetus
b

a

Fig. 20.9 â&#x20AC;˘ En face view of the interventricular septum in a fetus with interventricular septal defect. Ventricular septal
defect is recognized in the four-chamber view (a) (open arrow). With the same rendering technique as in Figure 20.8,
the en face view of the interventricular septum (b) demonstrates clearly the circular shape of this ventricular septal
defect and the complete area of the interventricular septum (dashed line) within the right ventricle. IVS interventricular septum, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle, VSD ventricular septal defect

a

b

c

Fig. 20.10 â&#x20AC;˘ Base of the heart on the atrioventricular plane. The volume-rendering box is placed in the four-chamber view
(a) over the atrioventricular valves, and the view direction (green line) is from the atria to the ventricles. Three-dimensional en face view (b) of the tricuspid and mitral valve seen from the base of the heart. Embedded between both ventricles is the aortic root, and anterior and on the left of the aorta is the pulmonary trunk. Pathologic specimen of a normal fetal heart (c) showing the base of the heart view demonstrated on 3D. AOV aortic valve, MV mitral valve, PV pulmonary valve , TV tricuspid valve

Fig. 20.11 • Base of the heart view in a fetus with atrioventricular (AV
( V) septal defect showing the common AV valve on
3D rendering (a). Pathologic specimen of a similar case (b) showing the common valve. Compare with the normal finding in Figure 20.10b. AO aorta, PT pulmonary trunk

a

b

Fig. 20.12 • Base of the heart view in a fetus with transposition of the great arteries in the 3D rendering (a) with the corresponding diagram (b). This view shows the aortic root to the right side and anterior to the pulmonary trunk. Compare
with the normal finding in Figure 20.10. AO aorta, MV mitral valve, PT pulmonary trunk, TV tricuspid valve

208

Echocardiographic Anatomy in the Fetus

Fig. 20.13 â&#x20AC;˘ Glass-body mode showing the aortic arch within the thoracic cavity on power Doppler

Minimum Transparent and Inversion Mode
Transparent minimum-mode rendering is a display
in which heart and blood vessels are seen in a transparent projection, mainly emphasizing structures with
highest transparency (anechoic) in a 3D projection
of black-appearing vessels (Fig. 20.15a), cysts,
bladders, etc. [21]. In the recently introduced inversion display mode, however, the minimum mode rendering information is simply inverted (as in a negative/positive film) (Fig. 20.15b), thus presenting the
hypoechoic structures as echogenic solid and eliminating into black most of the surrounding tissue information [22]. By changing some presets, such as
increasing the threshold and decreasing the transparency, the image is improved. Artefacts are eliminated by using the electronic scalpel MagicutÂŽ during volume manipulation (Table 20.1).
The image is similar to that acquired with color/
power Doppler but is very easy to obtain, as it is a
gray-scale acquisition with 3D or STIC. The disadvantage of inversion is that tiny vessels, such as pulmonary or brachiocephalic vessels, are not well
demonstrated due to the limited visualization on 2D
image at acquisition. Figure 20.16 shows a normal
heart with normally arising great vessels (Fig. 20.16a)
and a heart with transposition of the great arteries

Fig. 20.14 â&#x20AC;˘ Anterior view of the heart in power Doppler
showing a muscular ventricular septal defect (VSD) and the
crossing of the aorta and main pulmonary artery. The upper part of the heart was removed from the image to improve visualization of the VSD. AAO ascending aorta, LV left
ventricle, MPA main pulmonary artery, RV right ventricle, VSD
ventricular septal defect

(Fig. 20.16b), with a parallel course of the aorta and
main pulmonary artery.

Conclusion
In the recent years, 3D and 4D facilities have been
used in fetal echocardiography, especially with the
advent of the exciting acquisition technique STIC,
which allows imaging of a beating fetal heart. From
a volume data set, it is possible to obtain any plane
within the fetal heart at anytime during the cardiac
cycle. Volume data display can be achieved in planes
(single, orthogonal, tomography) and also as a rendered 3D volume in surface, glass-body, and minimum or inversion modes. The examiner should, however, know how to choose the appropriate slice thickness within the volume, the region of interest, and
the display mixture. As one might imagine, this new
technique may improve future detection rates of fetal cardiac anomalies and our understanding of spatial relationships of cardiac structures in complex cardiac malformations.
Clinically, the 3D/4D technique is used to store
volumes of cardiac anomalies for review of the findings at a later occasion or for a second opinion. In
some institutions, it is used as a tool for controlling

Fig. 20.15 • Two displays of a fetal heart volume: The transparent minimum mode (a) highlights the hypoechoic structures and shows a slice over the aorta and main pulmonary artery crossing each other. The inversion mode (b) is shown
in the same volume, which is the negative image of the minimum mode with a modelling of the surface. Without using
Doppler ultrasound, the crossing of the aorta and pulmonary trunk is demonstrated. AAO ascending aorta, LV left ventricle, MPA main pulmonary artery, RV right ventricle

a

b

Fig. 20.16 • Inversion mode of two hearts rendered from an anterior view. In the normal heart (a), the left and right
ventricles and the crossing of the aorta and main pulmonary artery (red arrows) are clearly seen. Transposition of the
great arteries (b) with the parallel course of both aorta and main pulmonary artery, with the aorta arising from the
right and the main pulmonary artery from the left ventricle. AAO ascending aorta, LV left ventricle, MPA main pulmonary
artery, RV right ventricle

screening examinations, where STIC is acquired by
the sonographers and reviewed by the specialist. It is
used in teaching courses, mimicking a live scan, for
fetal echocardiography to allow students to scroll

through volumes of cardiac anomalies and determine
the diagnosis. Finally, it is used in research to measure the volume of cardiac cavities and develop a stepby-step approach to demonstrate cardiac anomalies.

Introduction
The importance of autopsy in the event of fetal or
neonatal death is widely demonstrated in several studies [1-3]. Thanks to the diagnostic power now provided by cross-sectional echocardiography, most
structural and functional congenital heart diseases can
be identified during fetal life. However, it is unreasonable to expect 100% sensitivity in all cases. In fact,
many drawbacks can limit the ultrasonic examination,
such as gestational age at the time of scan, fetal
position, ultrasonic impedance of the maternal
abdomen, examiner experience, and types of equipment used. In case of termination or spontaneous intrauterine death autopsy is still a valuable tool that provides clinicopathological correlation for clinicians and
gives information to families regarding the risk of recurrence of specific diseases in future pregnancies. In
the latter instance, evaluations can be made earlier in
gestation, allowing informed decisions that will be in
the best interest of the mother and fetus. Performing
autopsies also provides the opportunity to create
archives of heart specimens with congenital diseases,
which are extremely useful for improving clinical practice, research, and education. Despite their small size,
fetal hearts with congenital heart disease are invaluable in teaching because they are free from surgical
manipulation, which usually modifies the native morphology in most postnatal specimens. Fetal autopsies
and specimen archives should be obtained after informed consent of the families according to their religious beliefs and according to local laws, avoiding
the inappropriate retention of organs such as that which
came to light in Europe a few years ago [4, 5].
The pathologist who addresses congenital heart
diseases in the fetus should be adequately trained and
maintain his or her expertise with a high workload.
Moreover, it is crucial to be familiar with the physiology and morphology of both normal and malformed
hearts, even the most complex malformations [6]. Ideally, the pathologist’s practice should be located at a
tertiary level in a pathology department and have close

links with other relevant subspecialties, such as fetal
medicine, obstetrics, pediatric cardiology and cardiothoracic surgery, and clinical genetics.

The Morphologic Study
Instrumentation
Because of the small dimensions of the fetal heart,
a suitable set of instruments is needed:
– a ruler, small scissors with at least one sharp point,
small scissors with two sharp points, fine probe
with rounded ends, blades, scalpel, needles, syringes, floppy guidewire, etc. (Fig. 21.1);
– a magnifying lens, and/or a dissecting microscope
preferably equipped with a camera;
– photographic equipment: camera, lenses, camcorder, image archiving systems;
– pathologist time and patience.
When a prenatal ultrasound diagnosis is available,
it should not influence the pathologist’s judgment but
offer, instead, the opportunity for a positive confrontation between echographer and pathologist.
Knowing the ultrasound diagnosis before starting the
autopsy is often useful to plan the best approach for
dissection.

Fig. 21.1 • A set of instruments commonly used for dissecting fetal hearts

212

Echocardiographic Anatomy in the Fetus

Exposure of the Heart and Great Vessels
The chest plate is removed by separating the sternoclavicular joint on each side while preserving the
jugular veins. Removing the pericardium and thymus
together allows exposure of the heart and great vessels (Fig. 21.2). The pericardium is nicked, and a cut
is made parallel to the diaphragm, extending it to the
terminal part of the inferior vena cava on the right
side and to the pulmonary veins on the left side. On
the right side, the pericardium is removed as close
as possible to the inferior vena cava and toward the
superior vena cava by reaching, without cutting, the
left innominate vein. On the left side, the scissors are
placed perpendicular to the diaphragm toward where
the pulmonary veins enter the left atrium. The pericardium, with the thymus attached, is dissected from
the left pulmonary artery and innominate vein without opening the lumen. If the innominate vein is absent, a persistent left superior vena cava should be
suspected. At the end, the pericardium is completely removed as close as possible to vascular insertions.
A sterile needle can be inserted in the lateral wall
of the right atrium to obtain blood culture if necessary. In general, we suggest removing the blood inside the heart and replacing it with a fixative solution,
such as methyl-Carnoy’s solution. This procedure also allows enhancement of the coronary morphology.

for the most appropriate anatomic dissection. The following list summarizes the most important points to
annotate during external examination:
– heart position and axis orientation;
– cardiothoracic ratio;
– visceroatrial arrangement;
– systemic and pulmonary vein connection;
– great arteries’ position and size;
– external morphology of atrial and ventricular
chambers;
– pattern of coronary arteries.
To best examine the heart and, in particular, to inspect the aortic arch, the arterial duct, and the descending aorta, we suggest moving the left lung to the
left (Fig. 21.2). If the heart can be moved from the chest
without displacing the lungs, an anomalous pulmonary
connection should be suspected (Taussig maneuver).
External examination of the heart in situ must be performed thoroughly, and every abnormality should be
annotated and possibly photographed, as many of them
are difficult or even impossible to identify once the heart
is removed from the thorax (Fig. 21.3).

Heart Examination In Situ
Examining the heart in situ may provide crucial information. Many congenital heart diseases can be
suspected from the outside, which allows planning

Fig. 21.2 • The chest plate has been removed to expose the
heart and the great vessels. The left lung is moved to the left
to inspect the aortic arch, arterial duct, and descending aorta

Fig. 21.3 • Chest and abdominal organs in situ. The liver is
a central structure with two nearly symmetrical lobes. The
intestines are malrotated. On external inspection, the heart
is in the right side of the chest, and there is a bilateral superior vena cava. The great arteries are malposed, with an
enlarged anterior aorta. The open arrowheads indicate the
diaphragm. AAO ascending aorta, LSVC left superior vena cava, mLA morphologically left atrium, mRV morphologically
right ventricle, RSVC right superior vena cava

CHAPTER 21 â&#x20AC;˘ The Role of the Pathologist in the Diagnosis of Fetal Heart Disease

213

Removal of the Heart and Lung Block

Dissection Following Blood Flow

The organs can be eviscerated in anatomically related
groups (Ghon method) or en bloc (Letulle method),
as in adult autopsy [7]. We usually prefer to eviscerate thoracic organs together with the trachea, the
larynx, and the esophagus. The carotid arteries should
be tied just above their bifurcation. To maintain separation between thoracic and abdominal organs, the
esophagus, aorta, and great veins are sectioned just
under the diaphragm (Fig. 21.4).

With this method, the heart is opened chamber after
chamber (examining each chamber as it is opened)
following the stream of blood and using the epicardial coronary arteries as marker of the position of the
ventricular septum. This method should be performed
following sequential segmental analysis from the venous to the arterial side. It usually requires a heart
specimen of sufficient dimension, which is rare in prenatal diagnosis. Even if this type of dissection can be
performed immediately after the heart is removed
from the chest, specimen fixation is recommended
(Fig. 21.5). In fact, when fixation is performed after
dissection, it results in distortion of the dissected edges
and alters the relationship of the cardiac structures.
This makes comprehensive pictures of the specimen
and morphologic study at a later stage difficult.

Methods of Heart Dissection
Different dissection methods can be employed [8, 9].
The method can be chosen on the basis of which
type of heart disease is suspected and specimen
size. More than one method is possible on the same
specimen.

Tomographic Method
Sections of this type allow morphologic sections
comparable with the echocardiographic views and
can be obtained from very small hearts. However,
accurate perfusion and fixation is required. Dissection should be performed with a sharp knife, avoiding a sawing motion, no earlier than 1-7 days after
fixation. Should the section so obtained be incorrect,
a new section can be performed after repairing mistakes. This can be done in a few hours after carefully gluing together the dried surface of the two
halves of the specimen with commercially available
cyanoacrylate glue.
Following are some examples of congenital
heart diseases displayed on different tomographic
sections of the heart.

Short-Axis Section

Fig. 21.4 â&#x20AC;˘ The heart and lung block in a fetal heart with
tetralogy of Fallot and pulmonary valve atresia. With the
help of a surgical suture (yellow
(
open arrows), the apex of
the heart is rotated to the right. The presence of the trachea allows recognition of a right-sided aortic arch and an
anomalous arterial duct that originates from the foot of the
left subclavian artery. AAO ascending aorta, AD arterial duct,
LAA left atrial appendage, LCCA left common carotid artery,
LSCA left subclavian artery, LV left ventricle, MPA main pulmonary artery, RAA right atrial appendage, RCCA right common carotid artery, RSCA right subclavian artery, SVC superior vena cava, T trachea

The heart is placed on its diaphragmatic surface, and
serial cuts are made parallel to the atrioventricular
groove. Slices so obtained correspond to the short
axis plane of the heart produced by cross-sectional
echocardiography. This method is indicated in a limited number of conditions, such as cardiomyopathy
or ischemic myocardial damage (Fig. 21.6).

The Four-Chamber Section
In this section, the cut begins at the cardiac apex
along a plane that passes through the acute and obtuse

214

Echocardiographic Anatomy in the Fetus

a

b

Fig. 21.5 • Outside (a) and inside (b) in a heart specimen of a fetus with tetralogy of Fallot and the so-called absent pulmonary valve. This specimen was fixated before dissection. Following the flow-of-blood method, the infundibulum and
pulmonary trunk are opened from the apex of the right ventricle (b). This cut allows evaluation of the ventricular septal
defect and the rudimentary pulmonary valve (arrowheads). To emphasize dilatation of the pulmonary trunk and left pulmonary artery and the absence of the arterial duct – a common finding in cases with congenital heart disease of this type
– the lumens of these vessels are windowed. AAO ascending aorta, LAA left atrial appendage, LPA left pulmonary artery,
PT pulmonary trunk, RAA right atrial appendage, RV right ventricle, SVC superior vena cava, VSD ventricular septal defect

S
R

L
I

Fig. 21.6 • Short-axis section of the heart in a 32-week gestational-age fetus who suffered a large myocardial infarction of the left ventricle due to thrombosis of the left main
coronary artery. The anterior portion of the interventricular septum and the anterolateral wall of the left ventricle
show extensive ischemic damage. A very large thrombus fills
the cavity of the left ventricle (asterisk).
k LV left ventricle, RV
right ventricle, TV tricuspid valve

Fig. 21.7 • Ebstein’s malformation in a 31-week gestationalage fetus This specimen is cut in a simulated four-chamber
section. Displacement of the tricuspid valve leaflets and the
atrialized portion of the right ventricle are well demonstrated (arrowheads). The enlarged foramen ovale with a redundant flap valve testifies to the obligatory right-to-left shunt
due to functional obstruction to the right ventricular outflow.
aRV atrialized right ventricle, FO foramen ovale, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle

margins of the heart and perpendicular to the inlet
and trabecular ventricular septum. This dissection allows assessment of the size of the cardiac chambers,
the atrioventricular junction and its valves, and the

atrial and ventricular septum (Fig. 21.7). After a section of this type, the ventriculoarterial junction and
great arteries should be examined with other methods of dissection, such as following the blood flow.

CHAPTER 21 • The Role of the Pathologist in the Diagnosis of Fetal Heart Disease

The Base of the Heart Section
Both atria are removed a few millimeters above the
mitral and tricuspid valve plane. This cut allows
assessment of the atrioventricular junction and
valves, the relative position of the great arteries,
and morphology and size of the semilunar valves
(Fig. 21.8).

Tomographic Section of the Whole Body
In echocardiography textbooks, tomographic sections of fetal cardiac specimens are usually compared with their corresponding echographic projections. These sections are generally obtained from
isolated hearts. However, tomographic sections of
the whole body are among the best techniques by
which to understand the relationship between cardiac and extracardiac structures. This understanding is particularly necessary in fetal echocardiography where the number of visible structures is
much greater and approaches to the fetal thorax are
variable. Nevertheless, specimens of the whole body
are rarely used because the process of fixation and
the methods by which to obtain these sections are
technically difficult and time consuming. In fact, the
section plane should be chosen with unforeseeable

a

215

result on the inner organs and with limited possibility of correction after the first cut has been performed. Sections of the whole fetal body are generally not applicable in abnormal cases, because the
standard reference lines on the external surface of
the body cannot be applied in most cases with congenital heart disease.
Sections of the whole fetal body, shown in other chapters of this book, have been obtained – according to Italian law and with maternal consent –
from four fetuses who underwent termination before 20 weeks of gestational age. The fetal body was
perfused through the umbilical vein and trachea
with Bouin solution, a liquid that allows good tissue fixation and satisfactory decalcification of the
skeleton. After fixation for 1 week, a series of parallel sections of the fetal body were performed with
a long blade along the horizontal plane, the true
sagittal plane, the parasagittal plane with 40°
clockwise orientation, and the parasagittal plane
with 60° counterclockwise orientation from the
sagittal midline in one fetus each. Each section was
classified and photographed using a professional,
digital, single-lens reflex camera with a macro lens,
mounted on a standard photographic stand. Sections
shown in this volume are the result of the close collaboration between the pathologist and the pediatric
cardiologist (Fig. 21.9).

b

Fig. 21.8 • Base of the heart in two fetal specimens with atrioventricular septal defect. Both images show the common atrioventricular orifice (black broken line) and the anterior (1) and posterior (2) bridging leaflet of the common valve. The ventriculoarterial connection is concordant without obstruction to ventricular outflow (a). The great arteries are therefore normally related and of equal size. However, the aorta is displaced anteriorly, compared with its position in the normal heart
where it is wedged between the two atrioventricular valves. A case with right isomerism (b). The ventriculoarterial connection is double outlet from the right ventricle. The aorta is enlarged and malposed, in anterior position. The black asterisk indicates the root of the atretic main pulmonary artery, located posteriorly. AO aorta, MPA main pulmonary artery

216

Echocardiographic Anatomy in the Fetus

Fig. 21.9 • Section of the whole fetal body obtained along
a true left parasternal sagittal plane. The relationship
between the heart and the thoracic and abdominal organs
is well depicted. The cranial portion of this image shows the
long-axis view of the arterial duct. Arrowheads indicate the
spinal cord

Windowing the Heart
This method allows a “window” to be opened with
a scalpel or scissors in the cardiac chambers or vessels by cutting out a portion of their wall to show
abnormalities inside. This type of dissection can be
applied to small hearts (Fig. 21.10).

New Technique for the Autopsy
The rate of postmortem examinations of newborns
and children has been declining over the last 30
years for different reasons, including the steady decline of parental consent and the reluctance of
physicians to subject the corpse to internal examination of organs [10, 11]. In 1990, Ros et al. [12]
proposed the use of magnetic resonance imaging
(MRI) as an alternative to the perinatal necropsy.
In fact, MRI provides good soft-tissue imaging, and
there are several advantages in the postmortem setting compared with its use in life: the absence of
motion artifacts, the unlimited acquisition time, and
the possibility of placing the receiver coil close to
the area of interest without concern for exposure
dosage, which allows high-resolution images. Several studies have reported that MRI in the fetus provides a detailed insight into fetal anatomy, pathology, and etiology in a wide range of abnormalities
[13]. Computed tomography (CT) scanning is superior to MRI for assessing bony structures and pro-

Fig. 21.10 • In this fetal specimen, the distal aortic arch, the
first portion of the descending aorta, and the main pulmonary artery are windowed to highlight an in utero closure of the arterial duct. AAO ascending aorta, AD arterial
duct, DAO descending aorta, InA innominate artery, LCCA left
common carotid artery, LSCA left subclavian artery, MPA
main pulmonary artery

vides excellent visualization of skeletal abnormalities, allowing data acquisition for further three-dimensional reconstruction. Excellent anatomical
evaluation is obtained by a combination of postmortem MRI and CT scanning. The documentation
and analysis of postmortem findings with CT and
MR imaging and postprocessing techniques (the socalled virtual autopsy) is noninvasive, less investigator dependent, and will probably lead to qualitative improvement in forensic pathologic investigation [14].
As to the cardiovascular system, there is general agreement that cardiac anomalies are difficult to
identify on postmortem fetal MRI [15–17]. This is
due to poor resolution of the technique for very small
structures, the loss of circulation, and clotting inside
the cardiac chambers. A learning curve is necessary
also, because image interpretation must be adapted
to postmortem conditions and the admitted inexperience with complex congenital heart diseases of most
investigators.
Because of the limited availability of the instrumentation, high costs, and limited experience of investigators, it is highly unlikely that MR/CT imaging will replace, in the foreseeable future, traditional autopsy examination of the fetal heart. However,
the new methodologies represent a new frontier and
will be a promising substitute for autopsy if combined
with minimal tissue sampling [18]. The role of the
pathologist in the field of the congenitally malformed
heart has been recently reviewed [19].

CHAPTER 21 • The Role of the Pathologist in the Diagnosis of Fetal Heart Disease

Because of the growing number of pregnancy terminations for fetal malformations detected very early in gestation, there is a growing interest to obtain
reliable autopsic studies on the hearts of very small
fetuses. A new technique, applicable in this setting,
was recently reported by Bussolati and colleagues
[20]. The technique first requires paraffin embedding
of the whole heart. Then, to allow proper alignment
of the sections, fiducial markers are introduced in the
block, close to the specimen. Three to four tissue
cores of anthracotic lymph node are introduced in the
block using a tissue micro arrayer, then serial sections are performed. Sections are stained with hematoxylin and eosin and scanned. Digital color pictures
are stored in JPEG format to be processed with dedicated software for 3D reconstruction [20, 21]. Threedimensional-model elaboration is obtained as a
mesh polygonal structure using a specific algorithm
model rendering. This is obtained with a rough wireframe model, with texture characterized by a specific
color and a particular degree of sheen and transparency. Once the model is created, the software allows navigation and, most importantly, virtual sectioning by clipping planes (Fig. 21.11). However, this
technique requires longer technical work time.

cur in isolation or are variably associated, an approach based on “pattern recognition” is doomed to
be unsuccessful. An embryogenetic approach to diagnosing and classifying cardiovascular defects is
confusing rather than helpful to the pathologist.
Pathologists need to apply the same type of approach
as the echocardiographer does, as most congenital
heart diseases show disordered morphology rather
than histological changes.
Diagnosis of any congenital heart malformation
requires the ability to recognize the morphological
features of each cardiac segment independently of its
location and to investigate the heart sequentially. Since
the first report – which revolutionized the diagnosis
of congenital heart disease [22] – sequential analysis has been reviewed [23, 24] on the basis of a new
concept that has proven its value in several fields. In
essence, one particular feature of the heart, which is
itself variable, should not be used as the defining feature for that particular cardiac component. Instead, the
component should be defined on the basis of its most
constant feature. Such sequential analysis is a simple descriptive approach that allows accurate and reproducible description of every heart, even those with
the most complex abnormalities.

Description of Cardiovascular Defects

Iconographic Documentation

Congenital heart malformations are usually considered to be too difficult to diagnose and describe. Because of the wide range of cardiac lesions that oc-

Good photographic documentation of the heart
is recommended, whether in situ or isolated, from
the outside before cutting and from the inside after

218

Echocardiographic Anatomy in the Fetus

cutting [25]. Such documentation is useful for diagnostic, research, teaching, and sometimes legal,
purposes. No descriptive words can replace the information obtained from high-quality images, either still-frame or video. Some technical suggestions follow.

tographed should be dried carefully. A polarizing filter on the camera lens and the light sources is recommended. This filter is useless if a flashlight is employed.

Choice of Equipment

In general, the background should be black and without reflections. Black velvet or flat black cloth is suitable (Figs. 21.12, 21.13).

Digital techniques now outweigh traditional photographic techniques. Digital images can be checked
immediately after the shot is taken, and pictures are
easily transmitted to other parties though different
forms of media and are more practical for archiving. Moreover, by avoiding the use of film, the
process of developing and printing is more economical. The use of a single-lens reflex camera with
interchangeable lenses is preferable, as it allows total control over angle, depth of field, and exposure
time. Because they are so small, fetal hearts require
the use of macro lenses.

Lighting
Two diffused light sources at a 45Â° angle should be
used for general lighting of the subject to be photographed. An additional spotlight can be employed
to highlight specific details and increase the 3D effect. Whenever possible, a flashlight is to be avoided. To prevent reflections, every surface to be pho-

Background

Image Quality
All digital cameras compress the photos before storing them on a flash memory card. The most common compression format is JPEG (Joint Photographic
Experts Group), which has the advantage of drastically reducing the size of an image but the disadvantage of losing part of the content. The higher the
compression, the lower the size of memory occupied.
Nearly all cameras provide at least three bands of
quality, which relate to different levels of compression. These levels are usually identified by the words
basic (the lowest), normal (standard), and fine (the
highest). The more sophisticated digital cameras also allow saving in TIFF (Tagged Image File Format)
format. TIFF is very widespread in the world of
graphics and publishing. This format allows a low
degree of compression and preserves all the information from the original snapshot. However, it has

b
a
Fig. 21.12 â&#x20AC;˘ The heart and lung block cut in a simulated four-chamber section to show a very large tumor filling the cavity of the right atrium (black asterisk)
k (a). To avoid reflections during photography, the surface of this specimen has been
thoroughly dried. The background is black velvet. The surface of the specimen is maintained horizontal by suspending
it on pins, which are hidden behind the photographed surface (b). LA left atrium, LV left ventricle, MV mitral valve, RA right
atrium, RV right ventricle, TV tricuspid valve

CHAPTER 21 â&#x20AC;˘ The Role of the Pathologist in the Diagnosis of Fetal Heart Disease

a

219

b

Fig. 21.13 â&#x20AC;˘ Light sources (outside the field of this picture) and camera are mounted on a stand (a). To open the lumen
of the cardiac chambers, the heart specimen is distended with a surgical suture fixed to two hypodermic needles stuck
into a foam board covered with black velvet as background. Close-up of the cardiac specimen shows atrioventricular valves
distended by the sutures (b)

the disadvantage of producing very large files. As an
alternative to TIFF, a third format is often available,
called RAW (crude). This format preserves all the
original information of the image, but it is not standard and may change depending on the manufacturer.
Computer software may be necessary to convert
RAW files into an international format. Contrary to
what one might assume, RAW and TIFF format files
offer very few tangible benefits over JPEG and conversely increase consumption of memory and battery
and image processing time. For everyday practice,
we recommend the JPEG format in fine or normal
mode, which virtually guarantees images of good
quality and occupies less space. Using JPEG format,
one should remembered that repeatedly saving the
same picture implies a loss of data, because the image is compressed after every change. It is therefore
good practice to keep the original image and produce
as many copies as there are changes one wants to
obtain. Fine standard is recommended for scientific
purposes when quality is essential and the maximum
resolution available is required. This is the only setting that allows enlarging a picture for small details
without losing definition.

Exposure Time and Depth of Field
Using a camera that allows setting the exposure time
and diaphragm is recommended. To achieve a high
depth of field, such as bringing into focus every
plane of the subject to be represented, a small lens
openings is required, usually F/8, F/11, F/16. Macro
lenses with small lens openings require long exposure times, even with strong light sources. Because
the shortest time for freehand shooting is 1:60 s, a
tripod or other stabilizer is essential if a longer exposure time is required. In general, the best results
are obtained with strong light sources, small diaphragm, and long exposure time, with the camera
fixed on a stand.
To hold the small specimens to be photographed
in the proper position, some tricks are useful. We
suggest using a foam or cork board covered with
the material chosen as background (see above).
Long straight pins can be used to fix or raise the
specimen in the required position (Fig. 21.12b).
Sometimes it is necessary to open the lumen of a
cardiac chamber or a vessel to improve the visual
angle inside. For this purpose, a very thin tensioned

220

Echocardiographic Anatomy in the Fetus

a

Fig. 21.14 • Polydactyly (a) and cleft palate (b) in a fetus with
trisomy 13. Aortic coarctation of complex type was associated. Although these extracardiac anomalies can be identified by prenatal ultrasound, they are frequently missed during a routine scan

suture on both edges of the cavity may enlarge the
cavity to be photographed. The end of the suture
can be fixed to the board with a hypodermic needle or a large pin (Fig. 21.13).

Conclusion
Despite major progress in imaging technologies in
prenatal diagnosis, clinical usefulness of traditional autopsy examination is still irreplaceable in the
field of fetal heart disease. Autopsy often provides
crucial information that allows identification of unsuspected associated anomalies (Fig. 21.14) and the
understanding of pathogenetic mechanisms of an
anomaly, thus affecting genetic counseling. Correlation between ultrasound and autopsy findings provides valuable educational information and improved accuracy of prenatal diagnostic imaging.
Among the new techniques, postmortem MR/CT
imaging will probably become an alternative to traditional autopsy, or at least an integral part of postmortem examination of the fetus and infant, indi-

b

cating the type of further examination necessary for
a given case.
Whatever the future scenario, a growing interaction between experts in the field of cardiology, fetal
medicine, pathology, and radiology will be required.
We agree with Dr. Sebire [18] that a new subspecialty
will probably develop in which the knowledge of the
fetal/pediatric pathologist, an expert of direct examination of the fetus with postmortem changes, organspecific pathology, and histopathological findings,
will be shared with that of the perinatal cardiologist
and the fetal medicine specialist, who are more confident with examining the morphology and physiology of the fetal cardiovascular system with cross-sectional and 3D ultrasound, and finally with the radiologist, who is best equipped in the technical aspect
of MR/CT image generation, acquisition, and manipulation. It is our belief that the approach to the
study of the fetal heart by projections, described in
the pages of this book, will be the common “language” for these experts, independent of the type of
imaging technique (morphological, ultrasonographic,
radiological, or by magnetic resonance) used.

CHAPTER 21 • The Role of the Pathologist in the Diagnosis of Fetal Heart Disease